13 Jul 2017 Edwin Lewis O'Donnell · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Failure to provide nurses with relevant prisoner escort information during first health reception screening 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
Edwin Lewis O'Donnell · 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
Edwin Lewis O'Donnell died on 23 October 2016 after being found unresponsive and hanging by a ligature from his cell tap; resuscitation was unsuccessful. The inquest found that his accidental death was contributed to by neglect, including failures to conduct an ACCT review, act on a referral for a mental health assessment, and escalate information that he had said he would be dead by 8.00 p.m.
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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 nurses with relevant prisoner escort information during first health reception screening
Wider context from the report “During the course of the inquest into the death of Edwin Lewis (Ned) O’Donnell it was apparent that a nurse carrying out the first health reception screening was not given access to the PER (Prisoner Escort Report) which had accompanied the prisoner from another prison establishment.
a) The PER form had content which was pertinent to mental wellbeing which was inconsistent with the information provided by Ned.
b) Though the previous prison indicated that they had sent a print from the digital IMR System One the nurse conducting the first health reception screening had no recollection or notes to indicate whether this was available at the time of the screening.
c) There is expected to be a second health screening of inmates some 24 to 48 hours later – which enables information from the community to be received and fuller informed access to the digital IMR System One. In this case the second screening was not until the 27th March 2016. Whereas the first screening was on the 9th March 2016.
d) An offender supervisor (Probation) working in the prison has been ACCT trained but did not know that there was a low threshold for opening an ACCT
The Court considers that in other cases important information in assessing risk could be missed if action is not taken to remedy these matters by making it a requirement that prison discipline staff record on C-Nomis all documentation received with a prisoner in particular
• PER forms
• SASH forms
• Printed summaries from System One
• Prescriptions
C-Nomis should also be noted that these have been handed to (or copies have been handed to healthcare in reception.
It could also be a mandated requirement that the digital IMR System One be updated (possibly when the digital IMR System Two is rolled out if that is imminent) with forced fields to ensure that nurses carrying out the first health reception screening record the documentation provided by the Prison staff which accompanied the prisoner.
The Court has heard evidence of the new training developed for the ACCT protocol and that this is being rolled out in a prioritised manner within HMP Liverpool. The Court considers it important that the Probation service takes responsibility to ensure that (offender managers and supervisors) probation staff working within prisons all receive basic ACCT training. Probation staff often have to break unwelcome news and this must require a risk assessment of the effects of that news on inmates.
” Source location Edwin Lewis O'Donnell · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide reception healthcare staff with Person Escort Records, brief relevant staff, and conduct spot checks of compliance.
Verbatim wording from the response “Information Sharing and Recording
Your first concern is that the member of healthcare staff carrying out the first health screening for Mr O’Donnell did not have access to the Person Escort Record (PER). Following the investigation into Mr O’Donnell’s death, the Governor tasked the Heads of Operations and Healthcare at the prison with devising a process to address this. The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to the healthcare member of staff based there, ensuring that they have access to all the relevant information. All reception staff, and healthcare staff who may work in reception, have been made aware of this process, and the Head of Operations carries out spot checks to ensure that it is being followed.” Source location 2017-0258-Response-by-HM-Prison-Probation-Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing information-sharing arrangements make recording receipt of documents on NOMIS unnecessary.
Verbatim wording from the response “In addition, you have suggested that receipt of the PER, Suicide and Self Harm forms, prints from SystmOne (the electronic patient record) and prescriptions should be recorded on NOMIS, and that a note should be made on NOMIS that copies of the documents have been handed to healthcare staff in reception. This would be time consuming for reception staff, and could involve changes to the NOMIS system that would come with a cost. On the basis that the system for sharing information with healthcare staff described above has been implemented, and that a PER is received with every prisoner who arrives at the prison, we do not believe it to be necessary to make these notes on NOMIS.” Source location 2017-0258-Response-by-HM-Prison-Probation-Service
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21 Jun 2017 Michael Folley · Prevention of Future Deaths report Central Hampshire
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Concerns raised 2
Failure to ensure clarity about information available during prison reception View source Failure to ensure receipt and training for important medical and risk information at prison reception 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
Michael Folley · 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
Michael Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.
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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 ensure clarity about information available during prison reception
Wider context from the report “During the inquest, it became apparent that despite extensive questioning of police/custody staff, GEOAmey staff, prison officers and healthcare professionals, it would not be possible to establish with any degree of certainty exactly what information was available during the induction process once Mr Folley arrived at prison.
I heard from prison officers and a senior nurse involved in the reception process but there was no clarity regarding exactly what information was available to them namely, the PER itself, the HDLS reports or information that had clearly been faxed to the prison by court staff such as the warrants setting out the grounds for the remand.
” Source location Michael Folley · 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 Failure to ensure receipt and training for important medical and risk information at prison reception
Wider context from the report “The nurse confirmed that at the time of Mr Folley’s reception checks he did not see the PER or HLDS reports but told me that he now does. In addition, he could not recall any specific training and the system for receipt of important medical information sounded haphazard as hardcopy documents were simply left on a desk .
” Source location Michael Folley · 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 Circulate reception-screening expectations and provide a Trust-wide reception-screening guide for staff.
Verbatim wording from the response “As part of suicide prevention, clear expectations on reception screening have been circulated to staff including:” Source location 2019-0230-Response-by-CNWL-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out standardised reception-screening training and competencies, restricting screening to trained and competent staff.
Verbatim wording from the response “The Trust is currently rolling out standardised training and competencies for reception screening. Reception screening is not allowed to be undertaken if the appropriate training has not been completed and the staff member deemed competent enough to carry out the reception screen.” Source location 2019-0230-Response-by-CNWL-NHS-Trust
Open published response
28 Mar 2017 John WILLIAMS · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to conduct the second reception screen View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Care UK
Maintain a register of missed Second Reception/Wellman assessments, arrange follow-up appointments through the Lead Nurse, and document patient refusals with scanned disclaimers.
View source
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AI-generated summary
John 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
John Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among prison officers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to conduct the second reception screen
Wider context from the report “2. There was no second reception screen conducted . If Mr Williams was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up.
” Source location John 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 Maintain a register of missed Second Reception/Wellman assessments, arrange follow-up appointments through the Lead Nurse, and document patient refusals with scanned disclaimers.
Verbatim wording from the response “As you heard in evidence, it is the case now that a register is kept of any Second Reception/Wellman assessments that are not completed. It is then the responsibility of the Lead Nurse to arrange for the” Source location Response from Care UK
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Lead Nurse is responsible for arranging follow-up and completion of missed Second Reception/Wellman assessments.
Verbatim wording from the response “As you heard in evidence, it is the case now that a register is kept of any Second Reception/Wellman assessments that are not completed. It is then the responsibility of the Lead Nurse to arrange for the” Source location Response from Care UK
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6 Dec 2016 Tedros Habtom KAHSSAY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3
Failure to explore recorded history of depression during reception screening View source Failure to apply objective clinical analysis during nurse reception screening View source Ambiguity in reception screening questions for identifying increased-risk prisoners View source
This report raised 12 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. 3
Care UK
Roll out the wellbeing wheel assessment, supported by online and face-to-face training, to explore mental health, physical health and substance-misuse issues in greater depth.
View source
Care UK
Replace the reception templates with an auditable, task-driven referral pathway that assigns greater accountability to the screening clinician.
View source
Care UK
Replace the prescriptive self-harm and suicide risk score with clinician-led exploration of presentation and relevant risk factors.
View source
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AI-generated summary
Tedros Habtom KAHSSAY · 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
Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring first aid.
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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 explore recorded history of depression during reception screening
Wider context from the report “6. The second reception (well man) screening nurse did not explore the history of depression recorded , he said because the prison general practitioner had not prescribed any medication for depression. On reflection, the nurse thought that he should have asked about it.
” Source location Tedros Habtom KAHSSAY · Prevention of Future Deaths report
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 apply objective clinical analysis during nurse reception screening
Wider context from the report “5. Both nurses conducting reception screening talked often in evidence about not being able to do anything other than accept the answers given by the prisoner. They did not seem to bring any objective analysis to the screening . The process of nurse screening appeared at times to be a tick box exercise .
” Source location Tedros Habtom KAHSSAY · Prevention of Future Deaths report
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 Ambiguity in reception screening questions for identifying increased-risk prisoners
Wider context from the report “4. The first reception screen template contained questions that carried an inherent ambiguity , in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased risk .
” Source location Tedros Habtom KAHSSAY · 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 Roll out the wellbeing wheel assessment, supported by online and face-to-face training, to explore mental health, physical health and substance-misuse issues in greater depth.
Verbatim wording from the response “We accept that the nurse could have explored the history of depression in greater detail. Our secondary reception screening process provides more time for this and we are in process of rolling out our wellbeing wheel assessment to support this assessment. The wellbeing wheel provides a structure for clinical staff to explore mental health issues in more depth alongside” Source location 2016-0437-Response-by-Care-UK.pdf
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 Replace the reception templates with an auditable, task-driven referral pathway that assigns greater accountability to the screening clinician.
Verbatim wording from the response “Concern 4. The first reception screen template contained questions that carried an inherent ambiguity, in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased risk.” Source location 2016-0437-Response-by-Care-UK.pdf
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 Replace the prescriptive self-harm and suicide risk score with clinician-led exploration of presentation and relevant risk factors.
Verbatim wording from the response “You heard evidence with regard to the new reception screening template and process. The scoring system in relation to the risk of self-harm or suicide has now gone as this was found to be too prescriptive. The focus is now placed on the member of healthcare who is screening the patient to explore the presentation and look into factors that may be relevant to suicide and or self-harm.” Source location 2016-0437-Response-by-Care-UK.pdf
Open published response
26 Jul 2016 Terence Darren ADAMS · Prevention of Future Deaths report Inner North London
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Concerns raised 4
Unavailability of the first night reception template key to the assessing GP View source Failure of the assessing GP to recognise the inpatient healthcare threshold in the first night reception template View source Failure to ensure staff understand the status of the first night reception template View source
Failure of the first night reception template to indicate that its instructions are advisory rather than mandatory View source See 1 more concern
This report raised 5 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. 2
Care UK
Roll out refresher training on the first-night reception template and its clinical guidance to all staff.
View source
Care UK
Review, approve and implement a revised first-night mental-health risk assessment with staff training, SystmOne integration and advisory clinical-judgement guidance.
View source
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AI-generated summary
Terence Darren ADAMS · 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
Terence Darren Adams committed suicide by hanging himself in his cell at HM Prison Pentonville. Concerns included failures in checking prison escort records, understanding and acting on the first night reception template, exploring his suicidal history, ensuring attendance at a follow-up reception screen, and sharing the root cause analysis needed for learning lessons.
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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 Unavailability of the first night reception template key to the assessing GP
Wider context from the report “2. The general practitioner (GP) who saw Mr Adams when he first arrived at HMP Pentonville did not have the key for the first night reception template when she considered the information contained therein. Mr Adams scored 8. The GP did not know that the advice on the template for scores of 6 and over was to admit the prisoner to inpatient healthcare.
” Source location Terence Darren ADAMS · Prevention of Future Deaths report
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 of the assessing GP to recognise the inpatient healthcare threshold in the first night reception template
Wider context from the report “2. The general practitioner (GP) who saw Mr Adams when he first arrived at HMP Pentonville did not have the key for the first night reception template when she considered the information contained therein. Mr Adams scored 8. The GP did not know that the advice on the template for scores of 6 and over was to admit the prisoner to inpatient healthcare .
” Source location Terence Darren ADAMS · Prevention of Future Deaths report
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 ensure staff understand the status of the first night reception template
Wider context from the report “3. Neither the nurse nor the GP conducting the first night reception interviews was clear about the status of the first night reception template . The nurse, particularly, talked about it being a document referring to historical matters, whereas the reality is that it encompasses both past and relevant current issues. The document did not give any indication on the face of it that its instructions are advisory rather than mandatory.
” Source location Terence Darren ADAMS · Prevention of Future Deaths report
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 of the first night reception template to indicate that its instructions are advisory rather than mandatory
Wider context from the report “3. Neither the nurse nor the GP conducting the first night reception interviews was clear about the status of the first night reception template. The nurse, particularly, talked about it being a document referring to historical matters, whereas the reality is that it encompasses both past and relevant current issues. The document did not give any indication on the face of it that its instructions are advisory rather than mandatory .
” Source location Terence Darren ADAMS · 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 Roll out refresher training on the first-night reception template and its clinical guidance to all staff.
Verbatim wording from the response “Response: This information was available in SystmOne for the General Practitioner. As a result of it having been overlooked, we will be rolling out a program of refresher training to all staff” Source location Response from Care UK
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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, approve and implement a revised first-night mental-health risk assessment with staff training, SystmOne integration and advisory clinical-judgement guidance.
Verbatim wording from the response “Response: There is an expectation that nurses undertaking reception duties within the prison complete an assessment of a person’s current risk of self-harm and suicidality when they are initially received into custody. This is particularly relevant as it is known that, for some prisoners, the early days of custody prove particularly stressful and so increase their risk. You heard the evidence of the Deputy Head of Healthcare who explained that, following another recent death in custody, we were already undertaking a review of the current risk assessment that is in use in reception in an attempt to improve its efficacy.” Source location Response from Care UK
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16 May 2016 Sheldon Woodford · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 1
Failure to make the SASH document identifiable to all relevant staff during reception 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
Sheldon Woodford · 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
Sheldon Woodford was found hanging in his prison cell on 9 March 2015 and subsequently died in hospital on 12 March 2015 after sustaining a significant hypoxic brain injury. The report identified concerns about the identification of the SASH document during reception, ACCT process training, staffing levels, and the unstructured application of the ACCT process, including inadequate integration between prison staff and healthcare.
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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 make the SASH document identifiable to all relevant staff during reception
Wider context from the report “(1)That in the reception process the SASH document is not identifiable to all relevant staff .
(2)Training of Officers in the ACCT processes.
” Source location Sheldon Woodford · Prevention of Future Deaths report
Open source report
7 Apr 2016 Matthew Colin SARGENT · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3
Failure to inform Healthcare staff when prisoners arrive with an ACCT history View source Failure to review available historical prisoner information at initial presentation View source Failure to supply Prisoner Escort Records to Healthcare staff at reception View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Practice Plus Group Hospitals Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Practice Plus Group Hospitals Limited
Review the reception screening process to develop a standard first-reception screening template across prison healthcare settings.
View source
Practice Plus Group Hospitals Limited
Update the SystemOne reception template to require staff to seek available information and record reasons when it is unavailable.
View source
Practice Plus Group Hospitals Limited
Ensure reception information-gathering processes are clear and effective.
View source
Practice Plus Group Hospitals Limited
Remind prison and healthcare staff to check the PER every time and escalate unavailable records through a Datix incident report.
View source See 1 more action
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AI-generated summary
Matthew Colin SARGENT · 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 Colin SARGENT was a serving prisoner who died in his cell at some time between 25 and 26 September 2014. The jury concluded that he committed suicide and raised concerns about the systematic, accurate and clear sharing of historical and current information between prison and healthcare departments.
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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 Healthcare staff when prisoners arrive with an ACCT history
Wider context from the report “(3) There was a concern that Healthcare staff were not made aware of prisoners who arrive with an ACCT history and it was suggested that Healthcare should be informed in all cases where a prisoner arrives at reception with an ACCT history so that there is a continued sharing of pertinent information.
” Source location Matthew Colin SARGENT · Prevention of Future Deaths report
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 review available historical prisoner information at initial presentation
Wider context from the report “(2) There was a concern that historical information which was available to Officers and Healthcare staff was not reviewed when the prisoner first presented at the prison and it was suggested that it would be beneficial if there was an instruction that any member of staff dealing with a prisoner who had access to historical information should make some enquiry as to that historical information so as to inform them of both the present and past risks.
” Source location Matthew Colin SARGENT · Prevention of Future Deaths report
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 supply Prisoner Escort Records to Healthcare staff at reception
Wider context from the report “(4) There was a concern that the Prisoner Escort Record (highlighting concerns and risks) was not supplied to the Healthcare Department and nurses at reception . It was suggested that this should be an imperative requirement for the further sharing of relevant information.
” Source location Matthew Colin SARGENT · 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 Review the reception screening process to develop a standard first-reception screening template across prison healthcare settings.
Verbatim wording from the response “As stated above, Care UK was not the healthcare provider at HMP Long Lartin at the time of Mr Sargent’s death. Going forward, the Care UK suicide prevention strategy will be shared and rolled out across all sites. In addition, since taking over healthcare responsibility on 1 April 2016, Care UK plans to review the reception screening process to introduce a standard template for first reception screening across its prison healthcare settings. We are also looking at the process of information gathering on reception and the culture around this. We will expect staff to ask ‘Where is the information for this patient?’ and the SystemOne template will reflect this, ensuring that staff cannot proceed without seeking out the information and recording reasons why, in instances where the information is not available.” Source location Matthew-Sargent-Response
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 Update the SystemOne reception template to require staff to seek available information and record reasons when it is unavailable.
Verbatim wording from the response “As stated above, Care UK was not the healthcare provider at HMP Long Lartin at the time of Mr Sargent’s death. Going forward, the Care UK suicide prevention strategy will be shared and rolled out across all sites. In addition, since taking over healthcare responsibility on 1 April 2016, Care UK plans to review the reception screening process to introduce a standard template for first reception screening across its prison healthcare settings. We are also looking at the process of information gathering on reception and the culture around this. We will expect staff to ask ‘Where is the information for this patient?’ and the SystemOne template will reflect this, ensuring that staff cannot proceed without seeking out the information and recording reasons why, in instances where the information is not available.” Source location Matthew-Sargent-Response
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 Ensure reception information-gathering processes are clear and effective.
Verbatim wording from the response “We will ensure our processes for obtaining information on reception are clear and effective and build relationships with local community providers to improve information flow. Furthermore, we will record lack of information at reception on our incident system so that we understand the extent of the issues and can monitor trends and share good practice. We recognise that we cannot rely solely on the first night reception and that on-going assessment over several days is essential in order to ensure we are aware of any changing clinical picture and to take account of any new information that arrives.” Source location Matthew-Sargent-Response
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 Remind prison and healthcare staff to check the PER every time and escalate unavailable records through a Datix incident report.
Verbatim wording from the response “In order to ensure robust communication and partnership working going forward we will continue to work closely with our prison partners on this and in particular, the Head of Healthcare is working to address the concern with the Safer Custody Governor. In addition, all (prison and healthcare) staff have been reminded that they must see the PER on every occasion and that non-access should be escalated within the prison via a datix incident report. If the staff member does not have access, an incident form should be completed as soon as it is apparent that a PER isn’t available.” Source location Matthew-Sargent-Response
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 Prison Service staff are responsible for examining and sharing PER and ACCT information with healthcare staff.
Verbatim wording from the response “These two points raise similar issues and can be answered together. It is the responsibility of prison service staff to share information with other departments and agencies both internal and external. PSI 74/2011 (First Days in Custody) sets out the requirement for the Person Escort Record (PER) form to be examined in Reception by prison staff to identify any immediate needs and risks and for this information to be forwarded to other staff and agencies as necessary, including healthcare. PSI 74/2011 sets out the mandatory requirements for prison staff and healthcare in respect of a prisoner’s ACCT status, ACCT alerts and risk assessments. Care UK thus expects PSI 74/2011 to be followed and that prison personnel will record a prisoner’s ACCT status on their record and share this and any concerns with Healthcare.” Source location Matthew-Sargent-Response
Open published response
Concerns raised 3
Lack of clarity about the designated recipient of SASH forms View source Failure of reception procedures under foreseeable high-demand conditions View source Failure of GEOAmey and prison reception staff to understand and keep each other informed about interconnecting procedures View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care UK Limited G4S Forensic & Medical Services (UK) Ltd GeoAmey PECS Limited 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. 7
HM Prison and Probation Service
Require reception staff to physically check, read, cross-reference and jointly sign prisoner documentation before escort departure, with daily staffing records and routine observation.
View source
GeoAmey PECS Limited
Engage with other agencies to develop and share best-practice procedures and documentation.
View source
HM Prison and Probation Service
Require reception staff to complete minimum online training before working in prisoner reception, with completion managed through learning plans and appraisals.
View source
HM Prison and Probation Service
Reissue and publish a reception-focused notice requiring documentation checks and warning of possible disciplinary action for failures.
View source
G4S Forensic & Medical Services (UK) Ltd
Instruct nursing staff to read and review all patient documents during reception screening.
View source
G4S Forensic & Medical Services (UK) Ltd
Remind staff through meetings and briefings to ensure all paperwork accompanying each prisoner is transferred with them on arrival.
View source
HM Prison and Probation Service
Hold monthly meetings between prison operations and the escort contractor to communicate procedural changes.
View source See 4 more actions
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AI-generated summary
Derek Thomas · 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
Derek Thomas died by suicide while in HMP Durham after arriving on remand and undergoing reception and first-night induction. Information suggesting suicidal intent was not adequately communicated or identified because of failures involving the SASH and PER forms across escort, prison reception and healthcare staff. The report raised concerns about procedures failing under demanding but foreseeable conditions, unclear inter-agency responsibilities, inadequate tracking of information, and poor interoperability between agencies.
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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 clarity about the designated recipient of SASH forms
Wider context from the report “(2) That the GEOAmey staff and Prison reception staff (including very experienced officers with both) had conflicting impressions of which Prison Officer (the one dealing with the warrants and Core record alternatively the one dealing with the property and the PER) was supposed to be the recipient of the SASH form. Training and refresher training as to their own procedures notwithstanding, there is a lack of appreciation by GEOAmey escort staff of the prison's reception procedures. There is a lack of awareness by prison staff of GEOAmey staff's ignorance of them. Alternatively, the prison reception staff develop the procedures without keeping GEOAmey staff informed. There is a tangible sense of one hand not knowing what the other is doing.
” Source location Derek Thomas · 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 Failure of reception procedures under foreseeable high-demand conditions
Wider context from the report “(1) That the circumstances on the 21st July 2014 at the reception included an inexperienced officer being on duty in conditions which were particularly onerous. It was described as the busiest he had ever seen by another more senior officer who was called away to deal with an incident, just at the time Mr Thomas was arriving in reception. Prison staff were adamant that another officer would have filled the gap left (although the identity of the substituting prison officer was not provided). These circumstances were clearly very demanding but they were not unforeseeable and may be repeated in future. When the procedures were “stress-tested” in the way they were on 21st July 2014, they failed so that a SASH form went unnoticed.
” Source location Derek Thomas · 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 Failure of GEOAmey and prison reception staff to understand and keep each other informed about interconnecting procedures
Wider context from the report “(2) That the GEOAmey staff and Prison reception staff (including very experienced officers with both) had conflicting impressions of which Prison Officer (the one dealing with the warrants and Core record alternatively the one dealing with the property and the PER) was supposed to be the recipient of the SASH form. Training and refresher training as to their own procedures notwithstanding, there is a lack of appreciation by GEOAmey escort staff of the prison's reception procedures. There is a lack of awareness by prison staff of GEOAmey staff's ignorance of them. Alternatively, the prison reception staff develop the procedures without keeping GEOAmey staff informed. There is a tangible sense of one hand not knowing what the other is doing.
” Source location Derek Thomas · 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 Require reception staff to physically check, read, cross-reference and jointly sign prisoner documentation before escort departure, with daily staffing records and routine observation.
Verbatim wording from the response “Reception – The Head of Operations at HMP Durham has instructed all staff working in reception that, prior to the escort contractor leaving the reception area, all documentation must be physically checked and read. The PER and all documentation must be cross referenced. It will be signed for by both staff. A daily detail is published which clearly identifies the members of staff who are working in reception on any given day and these are retained. The escort contractor has been informed of the process and is aware that the warrant and the SASH need to be handed to the supervising officer and the PER and property to the officer. All staff working in reception are expected to be competent in all areas of the process, both are situated side by side. A custodial manager and the Head of Operations will routinely observe this process.” Source location 2015-0502-Response-by-NOMS
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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 Engage with other agencies to develop and share best-practice procedures and documentation.
Verbatim wording from the response “We appreciate other agencies’ procedures and have devised and revised our SOPs to comply with the HM Prison Service’s requirements set out in the PSOs and PSIs. We engage in dialogue with other agencies (where possible) to develop best practice, procedures and documentation to be shared between the agencies.” Source location 2015-0502-Response-by-GEOAMEY
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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 Require reception staff to complete minimum online training before working in prisoner reception, with completion managed through learning plans and appraisals.
Verbatim wording from the response “Training – All staff working in reception must complete a level of training prior to working at the point in reception where prisoners are initially received. The level of training available to reception staff is an on-line course and a classroom based course. The Head of Operations at HMP Durham has deemed that as a minimum the on-line course must be completed. This will be managed by the individual member of staff’s line manager. It will be added to their individual learning path and monitored through the staff appraisal system” Source location 2015-0502-Response-by-NOMS
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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 Reissue and publish a reception-focused notice requiring documentation checks and warning of possible disciplinary action for failures.
Verbatim wording from the response “I note that your concerns are wider than the issues covered in the Governors Notice to Staff of 8 December 2015, however you may be interested to know that NOMS has been re-issued to primarily target reception staff. It outlines the importance of checking all documentation and advises that a failure to do so may result in disciplinary action. The Notice to Staff is published on the local prison intranet for a period of time. It is also available on the shared drive. The Head of Operations will also be positioning this on the front desk of reception for all staff working there to be constantly aware of. This will be followed up during staff’s individual performance reviews.” Source location 2015-0502-Response-by-NOMS
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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 Instruct nursing staff to read and review all patient documents during reception screening.
Verbatim wording from the response “The following further steps have been taken to address your concerns surrounding other issues arising at the inquest:-” Source location 2015-0502-Response-by-HMP-Durham
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff through meetings and briefings to ensure all paperwork accompanying each prisoner is transferred with them on arrival.
Verbatim wording from the response “The following further steps have been taken to address your concerns surrounding other issues arising at the inquest:-” Source location 2015-0502-Response-by-HMP-Durham
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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 Hold monthly meetings between prison operations and the escort contractor to communicate procedural changes.
Verbatim wording from the response “Communications between agencies – The Head of Operations at HMP Durham meets with the escort contractor on a monthly basis. Any changes in procedures are communicated at this meeting. The entire contract is managed by a NOMS monitor. Escort contractor managers make on-site visits to observe the process. There are seven individual providers that make up the healthcare function. A monthly prison operational and clinical governance meeting is held and any issues between the prison and healthcare can be discussed at this meeting.” Source location 2015-0502-Response-by-NOMS
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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 Unable to address individual staff and local HMP Durham issues because it no longer provides healthcare there.
Verbatim wording from the response “As you are aware Care UK Clinical Services Limited (“Care UK”) ceased to be the providers of primary healthcare services at HMP Durham and for the North East cluster of prisons on 31st March 2015 and as of 1st April the providers appointed was G4S Medical Services who I note are also copied into your letter.” Source location 2015-0502-Response-by-Care-UK
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The contractor has no remit over HMP Durham staff compliance with Prison Service Instructions.
Verbatim wording from the response “The PER and any other available documentation including the SASH Form must be examined and prisoner interviewed in prison reception to assess the risk of self-harm or harm to others as part of the Cell Sharing Risk Assessment (paragraph 2.18). The information is recorded and shared with other departments and agencies (e.g. Healthcare) internally and externally and actions are to be documented (paragraphs 2.19 and 2.20). We have no remit over HMP Durham staff (who are MOJ employees) and their compliance with the PSIs.” Source location 2015-0502-Response-by-GEOAMEY
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing procedures and systems are considered correct and sufficient for safe custody and escort, with focused training addressing the concerns.
Verbatim wording from the response “We have taken your concerns on-board. We refer you to Mr Airey’s statement. There has been no change to our procedures regarding the SASH Form or the PER. Following this Inquest there has been no request by the MOJ or PECS for our procedures to be revised. We remain of the view that we have the correct procedures and systems in place for the safe custody and escort of prisoners and the Jury’s conclusion and your concerns regarding the company can be properly addressed by the additional focused training in place which has been completed by over 90% of our officers with the remaining officers to complete it as soon as possible.” Source location 2015-0502-Response-by-GEOAMEY
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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 Requesting individual operating specifications from every establishment is not feasible because of the number of sites and resulting paperwork.
Verbatim wording from the response “There are 207 prisons from/to which we collect/escort 1,000s of prisoners per week. We also collect/escort prisoners from/to 100s of Courts, Police Stations and Detention Centres across the UK. It is not feasible for us to request from each establishment, nor for it to draw up, a specification sheet for individual operating processes. It would create an significant volume of paperwork for our officers.” Source location 2015-0502-Response-by-GEOAMEY
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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 Ministry of Justice has final responsibility for policy, procedures and documentation.
Verbatim wording from the response “The final say on policy, procedures and documentation is with the MOJ to whom we are contracted.” Source location 2015-0502-Response-by-GEOAMEY
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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 system is not dysfunctional; correct PER completion and document reading by prison and healthcare staff address interoperability concerns.
Verbatim wording from the response “It is unclear what further inter-operability could be put in place other than the correct completion of the PER by our officers (and/or others) and the reading of PER and SASH Forms by the prison and the Healthcare provider. Accordingly, we are of the view that the system is not “dysfunctional”.” Source location 2015-0502-Response-by-GEOAMEY
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26 Oct 2015 Wayne Patrick O'NEILL · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure to recognise the toxic significance of medication combinations during reception screening 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
Wayne Patrick O'NEILL · 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
Wayne Patrick O'NEILL was a serving prisoner at HMP Long Lartin who collapsed in his cell and died on 2 January 2013. The inquest recorded respiratory failure, bronchospasm following ingestion of propranolol, and asthma as the medical cause of death. Concerns included the prescribing of propranolol despite asthma, the combination of psychotropic medicines with potential cardiac effects, and the failure to undertake an ECG before 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 recognise the toxic significance of medication combinations during reception screening
Wider context from the report “(1) the evidence revealed that Mr O'Neill had died from one of two causes; either, as the jury found, he had taken propranolol illicitly which induced the broncho spasm that caused his respiratory failure. It is worth noting that Mr O'Neill had previously been prescribed propranolol and evidence was given at the inquest by a forensic psychiatrist that the fact it was contra indicated (given Mr O'Neill's asthma) appeared "to have been lost" to the prescribing clinicians at the time.
The alternative cause of death was that Mr O'Neill died from acute cardiac failure induced by the combination of psychotropic medication prescribed to him including citalopram, Olanzapine and amitriptyline.
An alert had previously been raised by the Medicines Healthcare Regulatory Authority warning against the prescribing of these drugs in combination.
An attempt had been made to take Mr O'Neill off these drugs but subsequent clinician had re-introduced them.
It was not clear from the evidence that when Mr O'Neill was screened in reception following his transfer from HMP Birmingham to HMP Long Lartin the significance of these combinations of medication was recognised.
Expert evidence was heard during the cause of the inquest notably from ████████ a Cardiologist. He said there was a strong case for ECG traces to be performed on all prisoners in receipt of this medication. This would reveal whether there was any prolongation of the QT interval.
The evidence revealed that an ECG trace had not been undertaken during the years that Mr O'Neill was an inmate at HMP Birmingham. A trace was arranged at HMP Long Lartin but had not taken place by the time of Mr O'Neill's death having only been requested as a matter of routine. The evidence suggested that the reason why the ECG was requested was due to an elevated pulse rate detected at the reception screen rather than recognition of the potentially toxic effects of the prescribed medication .
Evidence was given that obtaining an ECG trace is a simply, cheap and straight forward matter. It would seem sensible, accordingly for all the prisoners in receipt of this combination of medication to undergo ECG traces as part of the reception screening process.
” Source location Wayne Patrick O'NEILL · 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 Provide whole-nursing-team training to recognise medicines requiring ECG referral.
Verbatim wording from the response “• Training will be provided to the whole Nursing team with regard to recognizing medicines that should indicate a referral for an ECG. These medicines might readily be recognized by a Mental Health Nurse but not necessarily by a Primary Care nurse.” Source location 2015-0444-Response
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6 Sep 2015 Warren Martin Sampson · Prevention of Future Deaths report Essex
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Concerns raised 1
Lack of a process for following up non-attendance at Reception Healthcare first night screening View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Care UK
Undertake a second health screen within 72 hours of arrival, checking GP-record consent and recording refusals in SystmOne.
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AI-generated summary
Warren Martin Sampson · 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
Warren Martin Sampson had been remanded to HM Prison Chelmsford and was subject to an ACCT when he was found hanging in his cell. Concerns included inconsistent attendance and recording at ACCT reviews, no process for following up non-attendance at first-night healthcare screening, and no system ensuring officers were familiar with local directives and instructions.
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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 a process for following up non-attendance at Reception Healthcare first night screening
Wider context from the report “(2) The lack of a process for following up non- attendance at the Reception Healthcare first night screening
” Source location Warren Martin Sampson · 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 Undertake a second health screen within 72 hours of arrival, checking GP-record consent and recording refusals in SystmOne.
Verbatim wording from the response “The process now is that a Second Health Screen is undertaken within 72 hours of an inmate arriving at HMP Chelmsford and at that second health screen there would be a” Source location Response from Care UK
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.