Recurring concern

Failure to make significant medical events accessible to relevant non-clinical staff

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First reported 27 Oct 2014•Latest report 20 Feb 2015

Definition

What this concern includes

Includes failures to record, maintain or make significant medical events accessible to relevant non-clinical staff outside the primary clinical record, where those staff need the information for safety assessment, supervision or protective action; include the anchor's school-to-non-school information process and comparable clinical-to-discipline-staff recording arrangements in custody.

Not included

  • Excludes ordinary clinical record-keeping failures where the material problem is not making significant medical events available to relevant non-clinical staff.
  • Excludes generic inter-agency information-sharing failures without a specific significant-medical-event and non-clinical-recipient connection.
  • Excludes failures involving routine clinical handover between healthcare professionals or services.
  • Excludes prison-specific risk-information transfer where the concern is broader or different from recording significant medical events for access by non-clinical staff.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2014–2015

First to latest report issue date

Stated actions
1

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Ministry of Justice2
Department of Health and Social Care1
Downview Prison and Young Offender Institution1
HCRG Care Ltd1
St Edward's School1
Surrey and Borders Partnership NHS Foundation Trust1

Concerns and responses across reports

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

  1. Southampton and the New Forest

    AI-generated summary

    Daniel Stickland · 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

    Daniel Stickland, aged 17, was found collapsed after falling from his bed at his residential school on 14 May 2014, following two seizures earlier that day. He was taken to hospital and pronounced dead the following day; concerns included inadequate handovers, inaccurate or inaccessible logs, and no clear central method for recording significant medical events.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a clear central method for accurately recording significant medical events

    Wider context from the report

    “(4)No clear method of centrally and accurately recording significant medical events to facilitate passage of information to non -school persons. ”

    Source location

    Daniel Stickland · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  2. Portsmouth and South East Hampshire

    AI-generated summary

    GARRY GILBEY · 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

    Garry Gilbey developed worsening arm, chest and breathing symptoms while imprisoned and was later diagnosed with inoperable lung cancer after being admitted to hospital on 25 June 2012. He died on 3 July 2012. The substantive concerns included unclear ambulance-call procedures and emergency thresholds for prison officers, inadequate communication of healthcare events to night staff, and failures to ensure that specialist investigations were arranged, completed and properly checked.

    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 consistently record and flag key healthcare events between daytime and night-time staff

    Wider context from the report

    “3. There was no clear or consistent system to flag key healthcare events during the day and there seemed to be a variable practice/policy in place that not all healthcare staff seemed to be familiar with or followed so that less relevant information was recorded such as an additional pillown being supplied yet important information such as nebuliser treatment or having a low threshold for medical review if symptoms reoccur or worsen was not consistently recorded in a way that would enable daytime medical staff to flag prisoner healthcare concerns to night-time prison staff. ”

    Source location

    GARRY GILBEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing professional guidance requires accurate clinical records and sharing relevant information with colleagues, addressing handover and communication concerns.

    Verbatim wording from the response

    “The bodies regulating medical professionals have published comprehensive guidance for clinicians within the prison service, including communicating with non-clinical prison staff.”

    Source location

    2014-0533-Response-by-Department-of-Health
    Page 2 · response
    Published 10 December 2014

    Open published response
  3. Surrey

    AI-generated summary

    Chrylin Angela Maria Norrell-Goldsmith · 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

    Chrylin Angela Maria Norrell-Goldsmith was found shortly before midnight on 26 July 2013, partially suspended by a ligature in her cell at HMP Downview. CPR and subsequent paramedic efforts were unsuccessful, and the jury concluded that she took her own life. The principal concerns included exposed pipework in the cell, multidisciplinary input at ACCT reviews, retention of primary source data in the Phoenix Programme, and recording significant medical events in records accessible to prison discipline staff.

    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 record significant medical events in prisoner non-medical records accessible to discipline staff

    Wider context from the report

    “4. Recording Significant Medical Events on a prisoner’s Non-medical Records Consideration should be given to ensuring that all members of healthcare and In Reach staff working within a prison environment record all significant medical events that may impact upon a prisoner’s risk assessment for self-harm or suicide in a place or manner that is readily accessible to the discipline staff at the prison, in addition to any entry made in respect thereof in the System One record. ”

    Source location

    Chrylin Angela Maria Norrell-Goldsmith · Prevention of Future Deaths report
    Page 3 · 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

    Remind all staff to record significant self-harm and suicide-risk information on Cnomis as well as SystmOne.

    Verbatim wording from the response

    “All staff, including health care staff, will be reminded of the ACCT procedures and the requirement to record significant information about an individual’s self-harm or suicide risks, on Cnomis (Custodial National Offender Management Information System) in addition to recording the information on SystmOne- (the electronic medical records system). The induction pack available for health care staff has also been updated to include governance information about ACCT procedures and what information can be shared with non healthcare professionals.”

    Source location

    2014-0470-Response-by-NOMS
    Page 2 · response
    Published 27 October 2014

    Open published response
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Data last updated 7 September 2026