Recurring concern

Failure to recognise and respond to prisoners’ disability and neurodiversity-related needs

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First reported 9 Mar 2015•Latest report 30 May 2025

Definition

What this concern includes

Includes staff awareness, training, resources, recognition, adjustments and support arrangements directly concerned with prisoners’ physical, learning, developmental, personality-disorder or neurodiversity-related needs.

Not included

Generic prison staff training with no disability or neurodiversity connection
Clinical treatment failures unrelated to recognition or accommodation of these needs
Community disability support outside custodial settings

Reports: 9
Individual concerns: 10
Date range: 2015–2025
Stated actions: 15

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service5

Ministry of Justice3

Avon and Wiltshire Mental Health Partnership NHS Trust2

Greater Manchester Mental Health NHS Foundation Trust2

Avon and Somerset Constabulary1

Belmarsh Prison1

Care UK1

Cornwall Partnership NHS Foundation Trust1

Cygnet Health Care Limited1

Department of Health and Social Care1

Devon & Cornwall Police1

Devon Partnership NHS Trust1

Eastwood Park Prison and Young Offender Institution1

Elysium Healthcare Limited1

Gloucestershire Constabulary1

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.

30 May2025
Dorset
Concerns raised1
1. Lack of diabetes training and awareness among Prison Service staff
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Discussed local diabetes awareness needs with the healthcare provider at HMP The Verne.
  Stated by HM Prison and Probation ServiceStated completed
Respondent positions 2
1. Position
  Requiring all operational prison staff to undertake diabetes-specific training is unnecessary because training time is prioritised for higher-priority or broadly applicable topics.
  Stated by HM Prison and Probation ServiceNo action considered necessary
1. Position
  Training, guidance and diabetes awareness for prison staff are to be addressed by His Majesty’s Prison and Probation Service.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Colin David Lovett · 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

On 29 October 2022, Colin David Lovett was found collapsed and unresponsive in his room at HMP The Verne. The report raised concerns about prison staff’s lack of awareness and training regarding diabetes, limited out-of-hours healthcare access, and the support available to prisoners with insulin-dependent diabetes. It also identified concerns about telephone-call monitoring, access to medication, and the adequacy of risk management and support at HMP The Verne.

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 diabetes training and awareness among Prison Service staff
Wider context from the report
“(1) Evidence was provided by Prison Service staff during the Inquest that they have never received training about diabetes and there is a lack of understanding, and national guidance for Prison Service staff relating to the symptoms of a hypo glycaemic or hyper glycaemic attack, which can be fatal. (2) The healthcare department at HMP The Verne is only operated between 7.30am and 6pm daily and is not therefore available 24 hours a day. Outside of these operational times, access to healthcare would be via 111 or 999 which could cause delay in action being taken to resolve a hypo glycaemic or hyper glycaemic attack. This will be the position in other prisons nationally. (3) Whilst insulin dependent diabetics are likely to be experts in their own care, some prisoners may have poorly managed diabetes and require support which could be at any time. (4) It is acknowledged that there is a balance to be stuck with training non-medical individuals in diagnosing medical symptoms, which could lead to miss diagnosis, and ensuring care is provided without delay, however the Head of Healthcare at HMP The Verne stated that there would be benefit in providing an awareness to Prison Service staff of the impact on prisoners of long term conditions such as diabetes. (5) Several members of Prison Service staff gave evidence at the Inquest and only one, who had personal experience through a family member, had an understanding of diabetes and the impact it can have upon an individual, including the symptoms of a hypo glycaemic or hyper glycaemic attack. (6) Prisoners are dependent upon support provided by Prison Staff. I am concerned that the lack of awareness of the needs of prisoners with insulin dependent diabetes amongst Prison Service staff who provide care to prisoners at times when healthcare staff are not on site, could lead to future deaths. ”
Source location
Colin David Lovett · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Discussed local diabetes awareness needs with the healthcare provider at HMP The Verne.

Verbatim wording from the response
“This is precisely what has now happened at The Verne where following discussion with the Governor, the healthcare provider has provided a diabetes awareness and guidance document which has been disseminated to all staff.”

Source location
Response from HMPPS
Page 2 · response
Published 10 June 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Requiring all operational prison staff to undertake diabetes-specific training is unnecessary because training time is prioritised for higher-priority or broadly applicable topics.

Verbatim wording from the response
“I understand your concern to ensure that prisoners with diabetes receive high quality care. However, I do not believe that it is necessary or appropriate to require all operational prison staff to undertake specific training or awareness sessions relating to diabetes. Training time is limited and there are many other topics that are of higher priority and/or have more general application. Instead, where a healthcare provider identifies a need for prison officers to have increased awareness of diabetes (or any other particular medical condition) locally, they are able to raise this with the Governor and consideration can then be given to developing local awareness sessions, which can be delivered by healthcare staff as deemed necessary.”

Source location
Response from HMPPS
Page 2 · response
Published 10 June 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Training, guidance and diabetes awareness for prison staff are to be addressed by His Majesty’s Prison and Probation Service.

Verbatim wording from the response
“In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns related to healthcare services at the prison. Your other concerns regarding issues related to training, guidance and raising awareness of diabetes for prison staff are for the Director General Chief Executive of His Majesty’s Prison and Probation Service to address in their response to you.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 10 June 2025
Open published response
4 Dec2024
Avon
Concerns raised1
1. Lack of mandatory neurodiversity training for prison staff
This report raised 4 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.
Actions described in response 4
1. Action
  Provide neurodiversity training through core training, online modules and local staff induction.
  Stated by Eastwood Park Prison and Young Offender Institution and HM Prison and Probation Service and Ministry of JusticeStated completed
2. Action
  Employ Neurodiversity Support Managers to provide staff support and implement whole-prison neurodiversity processes and reasonable adjustments.
  Stated by Eastwood Park Prison and Young Offender Institution and HM Prison and Probation Service and Ministry of JusticeStated completed
3. Action
  Develop and make the National Neurodiversity Training Toolkit available to frontline prison and probation staff.
  Stated by Eastwood Park Prison and Young Offender Institution and HM Prison and Probation Service and Ministry of JusticeStated completed
1. Action
  Employ a Speech and Language Therapist and Neurodiversity Strategic Lead at Eastwood Park.
  Stated by Eastwood Park Prison and Young Offender Institution and HM Prison and Probation Service and Ministry of JusticeStated completed
AI-generated summary

Kayleigh Ann MELHUISH · 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

Kayleigh Ann Melhuish died on 7 July 2022 after being found hanging in her cell at HMP Eastwood Park and later taken to hospital. The report identifies concerns about staff understanding of neurodiversity, completion of ACCT care plans and support actions, use of constant supervision, and a ligature point in Residential Unit 3. The inquest concluded that suspension by a ligature contributed to the death by neglect.

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 mandatory neurodiversity training for prison staff
Wider context from the report
“1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff: a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory; b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews; c. Little or no understanding of when constant supervision can be used and how is it used; ”
Source location
Kayleigh Ann MELHUISH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide neurodiversity training through core training, online modules and local staff induction.

Verbatim wording from the response
“As you heard in evidence at the inquest, HM Prison and Probation Service (HMPPS) is undertaking significant work to understand and raise awareness amongst staff of neurodiversity issues and the impact that they can have in the custodial environment. In recognition of the importance of such issues, staff undergoing initial core training on diversity and inclusion, personality difficulties and neurodiverse conditions including autism are discussed and consideration is given to how staff can support prisoners with these needs. This training covers issues such as how best to conduct searches of individuals and how to manage disciplinary processes that may impact negatively on those with neurodiverse conditions. For existing staff, the online learning platform to which all staff have access”

Source location
Response from HMPPS/MoJ and HMP Eastwood Park
Page 1 · response
Published 9 December 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Employ Neurodiversity Support Managers to provide staff support and implement whole-prison neurodiversity processes and reasonable adjustments.

Verbatim wording from the response
“We have recruited Neurodiversity Support Managers (NSMs) across the prison estate to ensure that support for neurodiverse prisoners is consistent across all education, skills and work opportunities as well as the wider prison. One of the main responsibilities of the NSMs is to provide training and support for other prison staff to help them better understand and support those with neurodivergent needs within the prison. The NSMs are also responsible for implementing a whole prison approach to supporting neurodivergent needs with improved processes. This can include ensuring that all information and forms are available and/or designed with suitable adaptations, and that reasonable adjustments are made for prisoners with a disability so that they are not unfairly disadvantaged and can access all parts of prison life.”

Source location
Response from HMPPS/MoJ and HMP Eastwood Park
Page 2 · response
Published 9 December 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and make the National Neurodiversity Training Toolkit available to frontline prison and probation staff.

Verbatim wording from the response
“We have also developed a ‘National Neurodiversity Training Toolkit’ that is available for all frontline staff within prison and probation, developed by and with neurodivergent staff, in cooperation with HMPPS and Ministry of Justice staff networks.”

Source location
Response from HMPPS/MoJ and HMP Eastwood Park
Page 2 · response
Published 9 December 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Employ a Speech and Language Therapist and Neurodiversity Strategic Lead at Eastwood Park.

Verbatim wording from the response
“Eastwood Park has employed a Speech and Language therapist and a Neurodiversity Strategic Lead to work alongside the local NSM. The NSM delivers an introduction on neurodiversity to all new staff during their training period. This session includes highlighting common characteristics of neurodiverse people and best practices when working with them and provides staff with the opportunity to ask any questions they may have to deepen their understanding.”

Source location
Response from HMPPS/MoJ and HMP Eastwood Park
Page 2 · response
Published 9 December 2024
Open published response
20 Jun2024
Derby and Derbyshire
Concerns raised1
1. Lack of prison staff training and awareness on personality disorder and learning disability
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.

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

Yasmin Louise 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

Yasmin Louise ADAMS, who had emotionally unstable personality disorder and a history of self-harm, was found suspended and unconscious in her prison cell on 12 November 2016 and died in hospital the next day. Concerns included a 29-minute gap in observation checks, fixed shower rails presenting ligature risks, uncertainty about staff training on personality disorder and learning disability, and the use of cellular confinement for a prisoner on an ACCT.

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 prison staff training and awareness on personality disorder and learning disability
Wider context from the report
“3. There was lack of clarity concerning what training and awareness prison staff receive on personality disorder. Yasmin was diagnosed with emotionally unstable personality disorder which could make her behaviour impulsive, and unpredictable. She had also been diagnosed with learning disability in the community which was relevant to her understanding and communication with her. I have been provided with the training course slides for Introduction to Mental Health Awareness, produced by HMPPS Learning and Development in conjunction with the National Psychology Service. I am informed that this course is delivered to prison officer staff generally. There is nothing on the slides to indicate that the course covers personality disorder or learning disability. ”
Source location
Yasmin Louise ADAMS · Prevention of Future Deaths report
Page 3 · concerns
Open source report
15 Aug2023
Buckinghamshire
Concerns raised1
1. Lack of appropriate resources for maintaining neurodiversity management work
This report raised 4 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.
Actions described in response 1
1. Action
  Appoint a Band 6 neurodiversity support manager to raise staff awareness and provide toolkit-based training.
  Stated by HM Prison and Probation ServiceStated completed
AI-generated summary

Haik Patrick NIKOLYAN · 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

Haik Patrick NIKOLYAN committed suicide and was found unresponsive in his cell at HMYOI Aylesbury in the early hours of 11 March 2019. The inquest identified concerns including failures to protect him from harm, withdrawal of depression medication without documented risk assessment or enhanced monitoring, bullying and exploitation, ineffective safeguarding and communication, and inadequate consideration of his Autism Spectrum Disorder.

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 appropriate resources for maintaining neurodiversity management work
Wider context from the report
“Some three months further on, my concerns are heightened to the extent that a death may result in a variety of circumstances through the continuing significant issues HMP Aylesbury is encountering in recruitment and retention of experienced prison staff, particularly Grade 3 officers. Although initial steps are being taken towards implementation of a new neurodiversity plan, including the management of prisoners with autistic traits (pertinent to the circumstances of the death of Haik Nikolyan in 2019) and some recruitment has just taken place, without appropriate resources specifically in this area and within the broader staff cohort, there will be difficulties in maintaining this important work. ”
Source location
Haik Patrick NIKOLYAN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Appoint a Band 6 neurodiversity support manager to raise staff awareness and provide toolkit-based training.

Verbatim wording from the response
“This increase in staffing has allowed an improved regime to be offered to all prisoners, and has enabled the expansion of the key work provision, which gives enhanced support to prisoners. HMP Aylesbury have appointed a Band 6 Neurodiversity support manager to raise awareness of neurodiversity among all staff, and to provide training using the neurodiversity toolkit. The reception and induction will also be adapted to make them more accessible for neurodivergent prisoners.”

Source location
Response from HM Prison and Probation Service
Page 1 · response
Published 22 September 2023
Open published response
8 Nov2022
Inner South London
Concerns raised2
1. Lack of disability awareness among prison staff
2. Lack of accessible documentation of required disability adjustments
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Hold monthly disability-awareness training for operational staff, covering visible and non-visible disabilities, engagement, support, and access to adjustment documentation.
  Stated by HM Prison and Probation ServiceStated planned
2. Action
  Document required disability adjustments on the Prison Nomis system, accessible to prison, healthcare and social-care providers.
  Stated by Oxleas NHS Foundation TrustStated completed
AI-generated summary

Liridon Salikuка · 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

Liridon Saliuka was a remand prisoner at HMP Belmarsh who, after being moved from a medical cell to an ordinary cell without a special bed or mattress, hung himself in his cell on 2 January 2020. The report identified failures to recognise and accommodate his disability, inadequate care coordination and record keeping, and discriminatory and dismissive treatment. It also raised concerns about the lack of clear documentation of required adjustments and insufficient disability awareness among prison 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
Lack of disability awareness among prison staff
Wider context from the report
“2. To the Governor of Belmarsh. There was a lack of disability awareness amongst prison staff of all levels. For example, there was an assumption that a prisoner could not be disabled because he used the gym and had good upper body strength. ”
Source location
Liridon Salikuка · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of accessible documentation of required disability adjustments
Wider context from the report
“1. To the Governor of Belmarsh and to the Chief Executive of Oxleas. There was no clear documentation (accessible by prison staff, healthcare and social services) of the adjustments that were required for the prisoner’s disability, ”
Source location
Liridon Salikuка · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Hold monthly disability-awareness training for operational staff, covering visible and non-visible disabilities, engagement, support, and access to adjustment documentation.

Verbatim wording from the response
“In respect of your second concern, throughout 2023 HMP Belmarsh will be holding monthly training sessions alongside Oxleas NHS Trust and RGB for all operational staff. These sessions will focus on encouraging staff to think differently about disability, including those that may not be visible, and to take action to improve how they engage with disabled prisoners to ensure their needs are met, and the necessary support is offered. We will also remind staff on how to access the documentation detailing any adjustments, and the importance of doing so.”

Source location
Response from HM Prison and Probation Services
Page 2 · response
Published 9 November 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Document required disability adjustments on the Prison Nomis system, accessible to prison, healthcare and social-care providers.

Verbatim wording from the response
“When a patient is identified as requiring adjustments to their disability that these will now be documented on the Prison Nomis (P-Nomis) system. Agreement was reached following senior management review by HMP Belmarsh, Royal Borough of Greenwich Social Care and Oxleas NHS Foundation Trust. All these providers have access to p-nomis.”

Source location
Response from Oxleas NHS Foundation Trust
Page 1 · response
Published 9 November 2022
Open published response
23 Mar2020
Exeter and Greater Devon
Concerns raised1
1. Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Training on autistic prisoners’ needs is directed solely to the Prison Service and does not require a response from the Chief Constable.
  Stated by Avon and Somerset ConstabularyOutside remit
AI-generated summary

Lewis Charles Francis · 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

Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.

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
Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum
Wider context from the report
“(2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum ”
Source location
Lewis Charles Francis · 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
Training on autistic prisoners’ needs is directed solely to the Prison Service and does not require a response from the Chief Constable.

Verbatim wording from the response
“Action 3: It appeared desirable that training with regards to the special needs and susceptibilities of those prisoners within the autistic spectrum be provided for prison officers, support staff and newly appointed prison officers undergoing training both in the form of face to face training and the provision of information through prison intranet systems.”

Source location
2020-0074-Response-from-Avon-and-Somerset-Police_Redacted
Page 3 · response
Published 9 April 2020
Open published response
23 Jan2019
Inner North London
Concerns raised1
1. Failure of discipline and healthcare staff to recognise prisoners’ deafness
This report raised 7 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.
Actions described in response 5
1. Action
  Publish frontline staff guidance on disability and reasonable adjustments.
  Stated by HM Prison and Probation ServiceStated planned
2. Action
  Refresh the disability categorisation system with MOJ colleagues so NOMIS records are more efficient and descriptive than the existing yes-or-no method.
  Stated by HM Prison and Probation ServiceStated in progress
3. Action
  Develop a digital resource tool to collect personalised prisoner information and help staff identify appropriate adjustments.
  Stated by HM Prison and Probation ServiceStated in progress
1. Action
  Change healthcare communication systems by involving senior management in unusual cases, increasing equalities referrals and recording wing conversations in medical records.
  Stated by Care UKStated completed
2. Action
  Implement the Health and Wellbeing model at HMP Pentonville as an additional safety net for patients entering prison.
  Stated by Care UKStated completed
AI-generated summary

Tyrone GIVANS · 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

Tyrone Givans, who was homeless, profoundly deaf and had a history of alcohol and drug use, was remanded into custody at HMP Pentonville after being arrested for assault. The jury concluded that he hanged himself in his cell, although his intentions were unclear. Principal concerns included Spice use in prison, duplicated prison and healthcare records that prevented access to earlier assessments, and inadequate recognition and support of his deafness and disabilities.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of discipline and healthcare staff to recognise prisoners’ deafness
Wider context from the report
“3. Some members of discipline and healthcare staff did not appreciate that Mr Givans was deaf, although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer. There was a delay in seeking Mr Givans’ hearing aids and it took two weeks for one to be brought in by a family member. Whilst systems in HMP Pentonville have changed since Mr Givans’ death, such a situation might exist in prisons elsewhere. There remains no equalities/disabilities questionnaire for completion on prisoners’ arrival to the prison. The first night form could be adapted, but this would be an exercise to be undertaken nationally. ”
Source location
Tyrone GIVANS · 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
Publish frontline staff guidance on disability and reasonable adjustments.

Verbatim wording from the response
“In June this year, HMPPS will publish a Policy Framework document which will replace the existing Ensuring Equality Prison Service Instruction. It will include guidance on the implementation of reasonable adjustments, and will be complemented by the publication this summer of guidance for frontline staff on disability and reasonable adjustments.”

Source location
2019-0028-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 23 May 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Refresh the disability categorisation system with MOJ colleagues so NOMIS records are more efficient and descriptive than the existing yes-or-no method.

Verbatim wording from the response
“In terms of the recording of information about disability, we are working with colleagues in the MOJ to refresh the categorisation system for disabilities so that the recording of such information on NOMIS is carried out more efficiently and is more descriptive, moving away from the ‘Yes/No’ method of recording. This will provide staff with more valuable and usable information about the needs of prisoners in their care and across the estate. The categorisation of disabilities will be based upon the categorisation of impairment used by the Office for National Statistics and Government Statistical Service.”

Source location
2019-0028-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 23 May 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a digital resource tool to collect personalised prisoner information and help staff identify appropriate adjustments.

Verbatim wording from the response
“In addition to the above, a resource tool is being developed that will digitally collect more personalised information from prisoners, allowing staff to better understand their needs and identify adjustments that could be implemented to improve their quality of life and reduce unequal outcomes. This is currently in early development but we are looking to finalise proposals this month and to begin implementation in June/July 2019.”

Source location
2019-0028-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 23 May 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Change healthcare communication systems by involving senior management in unusual cases, increasing equalities referrals and recording wing conversations in medical records.

Verbatim wording from the response
“Care UK acknowledges that the identification of Tyrone’s disability and the communication of his need for hearing aids, and possibly for other adjustments, could have been better handled. As the Head of Healthcare, ████████, and Deputy Head of Healthcare, ████████, explained in evidence, changes have been made to systems of communication within healthcare and between healthcare and the prison. This includes involving the input of senior management in ensuring that action is taken and information is communicated by and to the most appropriate individual where unusual situations arise; increased awareness of, and referrals to, the prison’s equalities officer and a reminder to healthcare staff regarding making notes of wing conversations in the SystmOne medical records.”

Source location
2019-0028-Response-by-Care-UK
Page 2 · response
Published 23 May 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement the Health and Wellbeing model at HMP Pentonville as an additional safety net for patients entering prison.

Verbatim wording from the response
“A new Health and Wellbeing model has been implemented at HMP Pentonville with effect from 14 May 2018. In addition to its primary purpose, which is to deliver primary care mental health treatment whilst preventing silo working, reducing duplicate referrals and the time patients wait to be seen and preventing patients having the same conversation multiple times to various professionals, this acts as an additional safety net for patients coming into prison. We are confident that this would have identified Tyrone’s disability and enabled better management of his care.”

Source location
2019-0028-Response-by-Care-UK
Page 2 · response
Published 23 May 2019
Open published response
4 Jan2019
Manchester North
Concerns raised1
1. Lack of staff training and guidance for supporting prisoners with Asperger’s
This report raised 11 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.
Actions described in response 2
1. Action
  Deliver awareness events to improve staff confidence supporting prisoners with learning disabilities and other identified needs.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Develop and provide a learning-disability support toolkit with guidance and practical resources for prison and probation operational leaders.
  Stated by HM Prison and Probation ServiceStated completed
AI-generated summary

Mr Nicky Raymond Reilly · 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 Nicky Raymond Reilly, also known as Mr Mohamed Saeed-Alim, was an inmate at HMP Manchester after spending six years at Broadmoor High Security Hospital. He was found hanging by a ligature in his cell on 19 October 2016 and was pronounced deceased at 14.43. The report raised concerns about the lack of continuation of the Care Program Approach, incomplete multidisciplinary records and coordination, limited psychological input and record keeping, insufficient staff training, separation of mental health and psychology records, and medication-refusal processes.

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 staff training and guidance for supporting prisoners with Asperger’s
Wider context from the report
“The Court heard evidence as to the increase of prisoners within the Prison Service who potentially have a personality disorder or a degree of Aspergers and the limited services and places available. Of significance was the lack of training or guidance to staff on how to interact or accommodate someone with high functioning Aspergers such as NR. Please note the Court recognises the care provided by the SIU staff and the attempts some staff went to interact with NR, however there was no specific training or assistance given to them. ”
Source location
Mr Nicky Raymond Reilly · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver awareness events to improve staff confidence supporting prisoners with learning disabilities and other identified needs.

Verbatim wording from the response
“A number of establishments have delivered awareness events aimed at improving staff confidence in dealing with prisoners with these needs, and nationally a toolkit has been developed to help staff better meet the needs of those in our care with Learning Disabilities and Challenges (LDC). The toolkit is designed for prisons and for probation service operational leaders at prisons, helping them to look at how their support, services and surroundings can better meet those needs and provide a more equal and fair service for those with LDC needs. It includes resources and practical tips, such as how to display information and make environments more engaging and inclusive.”

Source location
2019-0014-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 24 May 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and provide a learning-disability support toolkit with guidance and practical resources for prison and probation operational leaders.

Verbatim wording from the response
“A number of establishments have delivered awareness events aimed at improving staff confidence in dealing with prisoners with these needs, and nationally a toolkit has been developed to help staff better meet the needs of those in our care with Learning Disabilities and Challenges (LDC). The toolkit is designed for prisons and for probation service operational leaders at prisons, helping them to look at how their support, services and surroundings can better meet those needs and provide a more equal and fair service for those with LDC needs. It includes resources and practical tips, such as how to display information and make environments more engaging and inclusive.”

Source location
2019-0014-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 24 May 2019
Open published response
9 Mar2015
Manchester City
Concerns raised1
1. Lack of psychological therapy identification and treatment for prisoners with personality disorders or related traits
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Craig Douglas Bell · 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

Craig Douglas Bell was found dead in his cell at HMP Manchester on 13 December 2012 after taking his own life by hanging using a self-constructed ligature. He had a history of self-harm and suicidal ideation and was subject to ACCT procedures. The principal concerns included inadequate sharing of risk information, insufficient senior psychiatric involvement in discharge planning, the lack of a graduated risk-management plan, and limited availability of safer or CCTV-monitored cells for prisoners at risk of suicide.

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 psychological therapy identification and treatment for prisoners with personality disorders or related traits
Wider context from the report
“1. The evidence established a significant unmet need for psychological therapies to treat patient prisoner suffering from personality disorders or those suffering from traits of such personality disorders. These prisoners are recognised as being at higher risk of self harm ( which may ultimately result in death ) or suicide. Without NHS Commissioners allocating more resources to identifying and treating such patients there is a concern that further prisoners suffering from these conditions will end up deliberately or accidentally killing themselves. ”
Source location
Craig Douglas Bell · Prevention of Future Deaths report
Page 5 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of diabetes training and awareness among Prison Service staff

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of mandatory neurodiversity training for prison staff

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Lack of prison staff training and awareness on personality disorder and learning disability

Concerns raised1

Lack of appropriate resources for maintaining neurodiversity management work

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised2

Lack of disability awareness among prison staff

Lack of accessible documentation of required disability adjustments

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

Concerns raised1

Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum

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

Concerns raised1

Failure of discipline and healthcare staff to recognise prisoners’ deafness

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Lack of staff training and guidance for supporting prisoners with Asperger’s

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

Actions described in response 1

Respondent positions 2

Actions described in response 4

Actions described in response 1

Actions described in response 2

Respondent positions 1

Actions described in response 5

Actions described in response 2