Recurring concern

Unreliable recording of security-search outcomes

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First reported 18 Jul 2018•Latest report 9 Sep 2024

Definition

What this concern includes

Includes failures in dedicated security-search processes to record, preserve or audit search outcomes, including items seized, negative search results, the nature or responsible staff of the search, and related records needed to confirm that searches were completed and handled safely.

Not included

Excludes failures in conducting or staffing searches where the search-recording process is not itself deficient.
Excludes general clinical, care, police or operational record-keeping failures that are not specifically connected to recording security-search outcomes.
Excludes searches for evidence, missing people or other objects where the process is not a safety-related search for prohibited or potentially harmful items.
Excludes failures to store, remove or dispose of seized items after their seizure when the search-outcome recording process was reliable.
Do not duplicate the existing broader concern concerning searches and screening for drugs and prohibited items; this proposal is limited to the recording and auditability of search outcomes.

Reports: 4
Individual concerns: 4
Date range: 2018–2024
Stated actions: 0

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.

Department of Health and Social Care1

Greater Manchester Mental Health NHS Foundation Trust1

Hoults Limited1

Inmind Healthcare Group1

Metropolitan Police Service1

Nbhd Group Limited1

Waterloo Manor Independent Hospital1

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.

9 Sep2024
West Yorkshire Eastern
Concerns raised1
1. Failure to record the nature, duration and responsible person for searches of returning patients
This report raised 3 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.
Respondent positions 1
1. Position
  Actions taken following the Serious Incident Report are considered sufficient to address identified issues and prevent similar future deaths.
  Stated by Inmind HealthcareExisting arrangements considered sufficient
AI-generated summary

Amanda Richardson · 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

Amanda Richardson, aged 40, was transferred from prison to a low secure mental health hospital and was found dead in her bedroom on 29 April 2023. Toxicology found a very high level of a prescribed drug, which had been prescribed at double the stipulated maximum dose, alongside evidence of illicit drug use. The concerns included inadequate medication review and monitoring, failures to record and investigate searches, and the adequacy of hospital security arrangements.

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 the nature, duration and responsible person for searches of returning patients
Wider context from the report
“3. On 19.4.23, Ms Richardson was permitted unescorted leave in the community under S.17 MHA 1983. She did not return. She did, however, voluntarily reappear at the hospital the following day, albeit under the influence of illicit drugs and alcohol. Evidence was given that nurses reported having searched Ms Richardson on her return, but no adequate written record was made to confirm the nature or duration of the search, nor by whom it was conducted, in breach of hospital policies. ”
Source location
Amanda Richardson · Prevention of Future Deaths report
Page 1 · 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
Actions taken following the Serious Incident Report are considered sufficient to address identified issues and prevent similar future deaths.

Verbatim wording from the response
“Inmind Healthcare remain committed to learning and improving service but given the assurances given to the Coroner at the Inquest, Inmind Healthcare consider that actions have been taken to fully address the issues identified by the Serious Incident Report and to prevent future deaths in similar circumstances.”

Source location
Response from InMind
Page 2 · response
Published 10 September 2024
Open published response
7 Feb2023
Manchester North
Concerns raised1
1. Failure to document outcomes of negative personal searches
This report raised 9 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.
Respondent positions 1
1. Position
  The Trust’s Search Policy already specifies recording whether searches find anything, and leave assessments include reasons for searches.
  Stated by Greater Manchester Mental Health NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Ania Sohail · 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

Ania Sohail collapsed on 19 June 2021 after ingesting Propranolol tablets she had obtained from multiple online pharmacies and died later that day from Propranolol toxicity. The principal concerns included the lack of integrated information sharing between online pharmacies and prescribers, ineffective and poorly documented searches, inadequate post-leave assessment and care planning, and insufficiently auditable observation records.

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 document outcomes of negative personal searches
Wider context from the report
“(4) There is no requirement for the outcome of negative personal searches to be documented in the records and consequently there is no ability to effectively audit whether searches are taking place and the treating team are unable to assess a patient’s level of compliance with rules around bringing contraband items onto the ward. ”
Source location
Ania Sohail · 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
The Trust’s Search Policy already specifies recording whether searches find anything, and leave assessments include reasons for searches.

Verbatim wording from the response
“(4) There is no requirement for the outcome of negative personal searches to be documented in the records and consequently there is no ability to effectively audit whether searches are taking place and the treating team are unable to assess a patient’s level of compliance with rules around bringing contraband items onto the ward.”

Source location
Response from Greater Manchester Mental Health
Page 3 · response
Published 22 February 2023
Open published response
19 Jul2018
Inner North London
Concerns raised1
1. Failure to record strip-search results
This report raised 18 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

Jeroen ENSINK · 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

Dr Jeroen Ensink was stabbed to death in a wholly unprovoked attack on 29 December 2015. The report identified multiple concerns involving police recording and information-sharing failures, including failures to identify and communicate possible mental health problems and issues in the handling of evidence and custody records.

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 strip-search results
Wider context from the report
“14. The booking in custody sergeant recorded authorisation of a strip search, but did not record the result of the search. ”
Source location
Jeroen ENSINK · Prevention of Future Deaths report
Page 4 · concerns
Open source report
18 Jul2018
Newcastle upon Tyne
Concerns raised1
1. Lack of written guidance on robust recording of items seized during searches
This report raised 8 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

Ellie Mae Knowles · 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

Ellie Mae Knowles attended a dance music event on 5 November 2016, consumed MDMA, became unwell, and later died due to methylenedioxymethamphetamine toxicity. The report identified concerns about event search procedures, record-keeping, staffing and future planning of similar events, including the continued existence of a licence for such events at the premises.

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 written guidance on robust recording of items seized during searches
Wider context from the report
“Although oral evidence of remedial action and change in practice was provided by Shindig Events Ltd, the Coroner remained concerned as detailed below: (1) No evidence was provided of written guidance/direction for Shindig Events Ltd employees and/or those with whom they subcontract of standards required in respect of: a. Numbers and qualifications of first aid staff to be provided at dance music events b. Robust recording by first aid staff of patients attended and action taken c. Numbers of security staff required at dance music events d. Scrutiny of the licence to operate status of security staff e. Extent of search of ticket holders required to be undertaken by security staff f. Robust system for recording items (including controlled drugs) seized at search and safe storage of those items ”
Source location
Ellie Mae Knowles · 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 raised1

Failure to record the nature, duration and responsible person for searches of returning patients

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

Concerns raised1

Failure to document outcomes of negative personal searches

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

Concerns raised1

Failure to record strip-search results

Concerns raised1

Lack of written guidance on robust recording of items seized during searches

Respondent positions 1

Respondent positions 1