23 Oct 2024 John Paul Hurst · Prevention of Future Deaths report Sunderland
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Concerns raised 1
Failure to record detailed information about detained persons’ mental health concerns View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Northumbria Police
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
Northumbria Police
Provide custody staff with instruction and learning on recording detainees’ mental-health concerns through the Custody Newsletter, Custody Compendium and direct reminders to Custody Sergeants.
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Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Review and update CJLD guidance for recording screening assessments, mental-health concerns, risks, clinical reasoning, referrals and handovers on electronic custody records.
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Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Circulate the updated operating procedure and train CJLD staff on required electronic-record entries and verbal handover documentation.
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Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Conduct monthly random audits of every CJLD staff member’s screening records and discuss audit outcomes in monthly clinical supervision to monitor implementation.
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AI-generated summary
John Paul Hurst · 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 Paul Hurst, who had a history of paranoid schizophrenia and previous suicide attempts, was released from custody on 13 September 2021 after concerns had been raised about his mental health and risk of suicide. He was found near train tracks on 15 September 2021 and died from haemorrhage associated with severe injury to his right leg, consistent with impact with a train. The principal concern was that the electronic custody record inadequately documented the mental-health and suicide-risk concerns, and lacked detailed analysis and reasoning for the CJLD assessment conclusion.
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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 record detailed information about detained persons’ mental health concerns
Wider context from the report “At the Inquest I heard evidence that, following John’s arrest, concerns were expressed by police officers involved in the investigation as to his mental health, and by John’s sister as to his risk of ending his own life. These concerns were repeated by John’s sister to the Criminal Justice Liaison and Diversion Service (CJLD) prior to his assessment. The evidence was that when completing the release risk assessment, the custody sergeant had been greatly assisted by the information recorded on the electronic custody record regarding the concerns that led to the mental health assessment and the assessment itself, in addition to the custody sergeant’s own observations. The evidence highlighted that the electronic custody record contained limited information about the concerns of police officers and John’s sister , and there was a distinct lack of detail about the assessment itself and very little analysis of the concerns and reasoning for the CJLD conclusion.
I am concerned that the information on the electronic custody record was inadequate and lacked detail regarding the concerns for the detained person’s mental health, as identified by police officers and family, including the risk of suicide, the content of notes found and the detained persons history of suicidal ideation and previous engagement with mental health services . In addition, I am concerned that the record also lacked a detailed analysis of those concerns by CJLD and comprehensive reasoning for the assessment conclusion.
” Source location John Paul Hurst · 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 custody staff with instruction and learning on recording detainees’ mental-health concerns through the Custody Newsletter, Custody Compendium and direct reminders to Custody Sergeants.
Verbatim wording from the response “I agree that it is important that custody officers record all relevant information and concerns expressed in relation to the mental health of a detainee. This is something which all custody officers should be aware of. In order to ensure that custody staff are aware of their obligations in this respect, following receipt of your report appropriate instruction and learning from this Inquest has been provided to custody staff via:” Source location Response from Northumbria Police
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update CJLD guidance for recording screening assessments, mental-health concerns, risks, clinical reasoning, referrals and handovers on electronic custody records.
Verbatim wording from the response “The Trust has carried out a thorough review of the guidance provided to staff in relation to entering information onto the electronic custody record and the following changes have been embedded:” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS
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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 Circulate the updated operating procedure and train CJLD staff on required electronic-record entries and verbal handover documentation.
Verbatim wording from the response “The updated Local Operating Procedure was circulated to staff on 12 November 2024 via email, please see "Exhibit A". Team training also took place on the 13 November 2024 to discuss the updated guidance. During” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS
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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 Conduct monthly random audits of every CJLD staff member’s screening records and discuss audit outcomes in monthly clinical supervision to monitor implementation.
Verbatim wording from the response “In addition, CJLD Clinical Leads have been given express permission by the Northumbria Police (Superintendent responsible for Custody), to audit Trust staff entries into the electronic custody record provided the reason for accessing the record is documented. Clinical Audit of CJLD screening documentation and will be carried out by CJLD Clinical Leads monthly for every staff member. Three random samples are selected for each staff member each month. Audit includes records made on both ECR and RiO. Audit outcomes are and will be discussed in monthly Clinical Supervision.” Source location Response from Cumbria, Northumberland, Tyne and Wear NHS
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Concerns raised 1
Lack of formal police documentation of family concerns about mental health deterioration View source
This report raised 11 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
Sussex Police
Add information received from detainees’ families to the custody care plan so concerns are formally recorded and addressed.
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Sussex Police
Complete and regularly review detainee risk assessments and care plans, recording changing physical or mental health information and responding to identified risks.
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AI-generated summary
Miles Ethan Hurley · 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
Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.
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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 formal police documentation of family concerns about mental health deterioration
Wider context from the report “2. Lack of relevant Documentation by the Police
Throughout Mr Hurley’s time in custody on the 9th July 2022, his parents spoke to multiple police officers and allied staff on the phone and on attending the custody suite to inform them of their concerns over their son’s sudden deterioration in his mental health on a background of longstanding extreme social anxiety. Whilst this was generally known by the officers within the custody suite, there was no formal documentation, either individually or collectively of these concerns to inform and assist police officers in their decision making .
” Source location Miles Ethan Hurley · 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 Add information received from detainees’ families to the custody care plan so concerns are formally recorded and addressed.
Verbatim wording from the response “A Custody Officer (Sergeant or Detention Officer) will complete an Initial Risk Assessment of the detainee on arrival and a Pre-Release Risk Assessment on their release from Custody. In every case a Care Plan is created to mitigate identified risk(s).” Source location Response from Sussex Police
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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 Complete and regularly review detainee risk assessments and care plans, recording changing physical or mental health information and responding to identified risks.
Verbatim wording from the response “A Custody Officer (Sergeant or Detention Officer) will complete an Initial Risk Assessment of the detainee on arrival and a Pre-Release Risk Assessment on their release from Custody. In every case a Care Plan is created to mitigate identified risk(s).” Source location Response from Sussex Police
Open published response
Concerns raised 1
Lack of audit trail for signed constant observation forms and sergeant briefings 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. 2
South Yorkshire Police
Conduct compliance dip sampling, including CCTV checks, to verify constant-observation briefings and supervisory checks.
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South Yorkshire Police
Consult the Performance and Governance team about activating body-worn video during constant observations.
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AI-generated summary
Matthew Terrill · 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 Terrill was taken into police custody on 22 April 2020 while intoxicated by multiple drugs and exhibiting behaviour associated with drug intoxication and possibly acute mental health symptoms. He was placed on level 4 constant observations, during which officers with limited experience and no briefing observed him until he was found not breathing. The substantive concerns included inadequate police training on drug intoxication, mental health symptoms, positional asphyxia, constant observations and custody handovers, as well as weaknesses in documentation and supervision processes.
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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 audit trail for signed constant observation forms and sergeant briefings
Wider context from the report “6. Lack of safety net for custody suit documentation, specifically the constant supervision forms.
I am told that whilst there has been a welcomed change to the format of the constant observation forms, there is no safety net for ensuring that these forms are handed over in a timely manner or by the custody sergeant. I am also told that there is no audit trail in place for checking that these forms are being signed by police or custody officers to ensure that the envisaged sergeant briefing is being given . I am concerned that there is a risk of future death to detained persons on level 4 constant supervision in circumstances where the sitting officers may not be experienced in the task, have not been trained, and are not consistently being briefed by the custody officers.
” Source location Matthew Terrill · 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 Conduct compliance dip sampling, including CCTV checks, to verify constant-observation briefings and supervisory checks.
Verbatim wording from the response “Training/ CPD will be given to all Custody Sergeants following this review setting out clear standards and expectations around their role and responsibilities of this document. Dip samples will be carried out by the Custody Inspectors to ensure compliance, this will include reviewing of CCTV to ensure that this document is briefed, relevant checks by the Sergeant are carried out for anyone under constant observations.” Source location Response from South Yorkshire Police and Humberside Police
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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 Consult the Performance and Governance team about activating body-worn video during constant observations.
Verbatim wording from the response “The Custody lead for South Yorkshire Police is to have further consultation with the Performance and Governance team to look at whether BWV should be activated when observing a prisoner, this could then capture the briefing, roles and responsibilities, action of the officers and any behaviour of the detainee.” Source location Response from South Yorkshire Police and Humberside Police
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8 Jun 2023 Ivan Rumenov Ignatov · Prevention of Future Deaths report Dorset
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Concerns raised 1
Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Dorset Police NHS England Niche Technology
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
Niche Technology
Seek customer-force views on changes needed to reduce recurrence risk.
View source
Niche Technology
Work with the Minerva Management Board to assess the reported risk-identification and recording issues.
View source
Dorset Police
Add a Custody Record dropdown menu to capture factors increasing detainee risk.
View source
Dorset Police
Amend Niche occurrence-log Section 2 to prompt consideration of detainee risk and vulnerability.
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AI-generated summary
Ivan Rumenov Ignatov · 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
Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue services.
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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 Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system
Wider context from the report “i. There is not sufficient clarity in the identifying, collating and recording of factors which may increase a person’s risk on the Niche system that Dorset Police, and other forces nationally, use and as a result information could be missed which is vital to a person’s risk assessment and their risk to themselves or others .
” Source location Ivan Rumenov Ignatov · 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 Seek customer-force views on changes needed to reduce recurrence risk.
Verbatim wording from the response “Action has already been taken which includes:” Source location Response from NicheRMS
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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 Work with the Minerva Management Board to assess the reported risk-identification and recording issues.
Verbatim wording from the response “However, given the significant nature of the issue you have raised, I would expect forces, as a minimum, to have received some more permanent solution to the concern you have outlined when they next upgrade. And, given that most Niche forces upgrade on an annual basis, this will have an immediate impact on the risks presented by the lack of clarity in identifying, collating and recording risk factors in NicheRMS365. I can reassure you that, together with colleagues from MMB, we are actively looking at the issues you have raised.” Source location Response from NicheRMS
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a Custody Record dropdown menu to capture factors increasing detainee risk.
Verbatim wording from the response “We have updated the Niche system in a way that we believe addresses this concern. A dropdown menu is now included in the Custody Record for every detainee for the purposes of capturing such information.” Source location Response from Dorset Police
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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 Amend Niche occurrence-log Section 2 to prompt consideration of detainee risk and vulnerability.
Verbatim wording from the response “In short, we are in the process of implementing changes to Niche, locally, which will see Section 2 of Occurrence Logs on Niche amended, to prompt the Custody personnel to consider risk and vulnerability regarding the detainee in question.” Source location Response from Dorset Police
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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 Niche Technology cannot require customers to install patches or activate specific RMS changes.
Verbatim wording from the response “I would not wish to pre-empt recommendations of the Minerva Criminal Justice Working Group on this matter, so the method of change is not presently clear. Further, I have not seen the response from the College of Policing who may issue additional guidance and changes to the risk assessment process that will need to be factored into any change we make to the RMS. I note also, that Niche Technology can not insist that customers install patches or turn on any specific change in their upgrades.” Source location Response from NicheRMS
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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 Many concerns in the report fall outside NHS England’s remit, so it can comment only on matters relevant to its functions.
Verbatim wording from the response “It should be noted that many of the concerns raised in your Report do not fall under NHS England’s remit and I am only able to provide comment on those concerns relevant to NHS England. I note that you have addressed your Report to several parties involved in Ivan’s case, to include Dorset Police, who are better placed to respond to many of the concerns raised.” Source location Response from NHS England
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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 Dorset Police are better placed to respond to many concerns addressed to multiple parties involved in the case.
Verbatim wording from the response “It should be noted that many of the concerns raised in your Report do not fall under NHS England’s remit and I am only able to provide comment on those concerns relevant to NHS England. I note that you have addressed your Report to several parties involved in Ivan’s case, to include Dorset Police, who are better placed to respond to many of the concerns raised.” Source location Response from NHS England
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7 Dec 2021 ANTHONY JAMES FITZPATRICK · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to ensure that recorded risk grades have a clear shared meaning View source
This report raised 2 other concerns. 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
ANTHONY JAMES FITZPATRICK · 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
Anthony James Fitzpatrick had a long history of mental health problems and attended local A&E departments on three occasions in the year before his death, with two attendances followed by custody. The report identified inconsistent and inaccurate assessment of risk by healthcare professionals, with unclear risk grades recorded in the electronic custody record and no plan to address the problem despite it being known.
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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 that recorded risk grades have a clear shared meaning
Wider context from the report “(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of ████████, meaning that (a) the grade of risk assigned to AF was inconsistent and/or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record .
(2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials.
(3) Despite being aware of this problem, there was no plan in place to address it.
” Source location ANTHONY JAMES FITZPATRICK · Prevention of Future Deaths report
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28 Aug 2020 Carlington Maurice Spencer · Prevention of Future Deaths report Lincolnshire
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Concerns raised 1
Inaccurate, irregular and unavailable records of incapacitated detainees View source
This report raised 17 other concerns. 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
Carlington Maurice Spencer · 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
Carlington Maurice Spencer, a detainee at Morton Hall IRC, suffered a right middle cerebral artery infarction after being found unwell and was later confirmed deceased on 3 October 2017. The report identifies concerns about confirmation bias relating to presumed drug use, inadequate monitoring and record keeping, poor communication and escalation between discipline and healthcare staff, failures to recognise stroke symptoms, and delays in emergency treatment.
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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 Inaccurate, irregular and unavailable records of incapacitated detainees
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel ;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice";
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory;
” Source location Carlington Maurice Spencer · Prevention of Future Deaths report
Open source report
23 Jul 2019 Adam Harris · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Delays in opening and entering information in custody records View source
This report raised 6 other concerns. 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
Adam Harris · 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
Adam Harris died at Tameside General Hospital on 20 April 2018 from alcohol and cocaine toxicity after collapsing at Ashton Police Station following his arrest and detention. Concerns included the absence of documented triage or risk assessment while prisoners waited in the van dock, lack of searches before transport, unclear handover arrangements, delayed creation of the custody record, and inconsistent evidence about his position in the cell while confused and suspected to be intoxicated.
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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 Delays in opening and entering information in custody records
Wider context from the report “4. The Custody Sergeant did not open a custody record immediately on Adam Harris’s arrival in the custody office . He used a piece of paper to record the details that were given to him. He did not input details into the custody record until after Adam Harris had been placed in a cell . He indicated that the custody Sergeant course encouraged the use of paper and he had developed his practice from the guidance on the course. It was unclear how the paper was stored and how it supported the requirement to follow the process generated through using the custody system;
” Source location Adam Harris · Prevention of Future Deaths report
Open source report
19 Jul 2018 Jeroen ENSINK · Prevention of Future Deaths report Inner North London
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Concerns raised 4
Failure to accurately record suspected cannabis use View source Failure to maintain consistent and accurate recording of alleged weapon threats View source Failure to record force used during arrest View source
Failure to accurately record detainee injuries View source See 1 more concern
This report raised 15 other concerns. 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
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.
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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 accurately record suspected cannabis use
Wider context from the report “9. Both arresting officers thought there was a possibility that ████████ was under the influence of cannabis. The custody sergeant recorded this as heavy cannabis use , he said because in his experience people who use cannabis use it heavily .
” Source location Jeroen ENSINK · 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 maintain consistent and accurate recording of alleged weapon threats
Wider context from the report “4. The custody sergeant who booked ████████ into custody recorded that ████████ had threatened police officers with a knife , though there was no mention of this on the CRIS (crime record information system) report or in the officers’ statements , and both officers gave evidence at inquest that ████████ had not had a bladed article in his possession when they arrested him. This was later found on the windowsill through which he had climbed into the property.
” Source location Jeroen ENSINK · 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 record force used during arrest
Wider context from the report “6. The arresting officers described in evidence a violent struggle with ████████ when they arrested him. He had tried to grab the Taser belonging to one of the officers. Yet the custody sergeant recorded that no force had been used . And this was despite the fact he said that he was under the impression that ████████ had wielded a knife against the officers. He said in evidence this was because the force had been used outside the police station .
” Source location Jeroen ENSINK · 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 accurately record detainee injuries
Wider context from the report “5. The custody sergeant noted that ████████ had a bruised, bleeding and swollen lip , yet to the custody record question regarding any injuries, he recorded no .
” Source location Jeroen ENSINK · Prevention of Future Deaths report
Open source report
21 Jun 2017 Michael Folley · Prevention of Future Deaths report Central Hampshire
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Concerns raised 1
Failure to record checks of PER completion and quality View source
This report raised 12 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 record checks of PER completion and quality
Wider context from the report “e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry . This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded .
f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody officers.
” 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 Use the next custody newsletter to reinforce PER completion, inspection, warning-page, envelope, risk-marker and external-information responsibilities.
Verbatim wording from the response “Force Custody publishes a quarterly newsletter to all custody officers and detention officers. The next publication is due in September 2019 and will reinforce the issues addressed in this Regulation 28 Notice.” Source location 2019-0230-Response-by-Hampshire-Constabulary
Open published response
8 Mar 2017 Mr Valdas Jasiunas · Prevention of Future Deaths report East London
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Concerns raised 1
Custody-record systems that readily permit errors View source
This report raised 2 other concerns. 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
Mr Valdas Jasiunas · 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
Mr Valdas Jasiunas, who had serious underlying health problems including chronic alcohol liver disease and seizures, was arrested and held in police custody on 1 September 2010. He collapsed in his cell the following morning and died in hospital on 2 September 2010. Concerns included the identification and management of alcohol dependency, erroneous custody-record entries that could provide false reassurance, and communication difficulties where English was not the detainee’s first language.
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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 Custody-record systems that readily permit errors
Wider context from the report “2. An erroneous entry was inserted into Mr Jasiunas’ record by an FME. The entry had the effect of providing false assurance to custody staff. The evidence revealed that errors on the custody records are commonplace and that the current design of the system renders errors easily made . Suggestions for improvements of the system included photographs of the detainee on the computer system; more prominent indication of the detainees surname at the top of the medical form; pop-up prompts to remind the healthcare practitioner to ensure that they have identified the correct detainee before prescribing medication; changes to prevent medication from being entered onto a person’s custody record in the absence of an accompanying medical form being completed at the same time.
” Source location Mr Valdas Jasiunas · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.