Recurring concern

Unreliable recording and involvement of prisoners’ next of kin

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First reported 31 May 2024•Latest report 10 Mar 2026

Definition

What this concern includes

Includes failures in prison processes to obtain, verify, maintain or make accessible next-of-kin details, and failures to involve or communicate with next of kin about significant care, welfare, safety or other decisions where their involvement is appropriate, including the anchor’s missing process at HMP Guys Marsh and comparable failures involving inaccurate records, absent details, delayed communication or omitted involvement.

Not included

  • Excludes generic family communication, complaint handling or care-planning failures where next-of-kin identification or involvement is not the material unsafe condition.
  • Excludes failures involving patients’ or residents’ families outside a prison or custody context unless the assertion explicitly supports the same next-of-kin process.
  • Excludes failures to provide treatment, supervision or care where next-of-kin information and involvement were reliable.
  • Excludes ordinary confidentiality or consent restrictions where they appropriately prevent disclosure or involvement.
  • Excludes the existing narrower concern concerning usable family contact details where the assertion is limited to obtaining or retaining contact details and does not support the broader next-of-kin recording-and-involvement condition.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2024–2026

First to latest report issue date

Stated actions
2

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1
Government Legal Department1
Guys Marsh Prison1
HM Prison and Probation Service1
Midlands Partnership University NHS Foundation Trust1
Ministry of Justice1
NHS England1
Practice Plus Group1
Recipient name withheld1
Unilink Software Limited1

Concerns and responses across reports

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

  1. Worcestershire

    AI-generated summary

    Surendrakumar Patel · 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

    Surendrakumar Patel died at Alexandra Hospital, Redditch, on 31 October 2024 after collapsing with a lower respiratory tract infection, with self-neglect through malnutrition contributing to his death. While on remand at HMP Hewell, he stopped eating, expressed that he no longer wished to live, lost weight, and developed acute kidney injury. The report identified concerns about healthcare staff’s failure to recognise the need for a timely mental capacity assessment, consider hospital transfer and expedited senior medical and psychiatric assessment, and consider family contact; prison staff also lacked awareness of procedures for informing or consulting next of kin about food refusal.

    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 inform Next of Kin of a prisoner’s decision to refuse food or fluids

    Wider context from the report

    “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy: a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began b. Failure to consider hospital transfer for prisoners severely weakened by weight loss c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival d. Failure to consider and advocate for family contact 2. Prison staff lacked awareness of HMP Hewell food refusal policy, including: • Not informing Next of Kin of the prisoner’s decision to refuse food/fluids • Not asking the prisoner whether such information should be shared ”

    Source location

    Surendrakumar Patel · 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

    Deliver awareness sessions to prison and healthcare staff on supporting prisoners who refuse food, including contact with next of kin.

    Verbatim wording from the response

    “HMPPS recognises the importance of family involvement at times of increased vulnerability including where a prisoner is refusing food and/or fluid. A joint review of HMP Hewell’s food refusal policy has since been undertaken in partnership with healthcare colleagues. This review has strengthened clarity around the consideration of contact with next of kin when a healthcare professional identifies a serious risk to an individual’s health. Following the completion of the review, awareness sessions will be delivered to prison and healthcare staff involved in managing and supporting prisoners who refuse food, including contact with the next of kin, to support consistent, compassionate, and informed practice.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 12 March 2026

    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

    The food and fluid refusal pathway is considered robust and fit for purpose regardless of the reason for refusal.

    Verbatim wording from the response

    “This does not mean that Practice Plus Group has not reflected on this case. The outcome of the Inquest follows a period whereupon the food and fluid refusal pathway has robustly been tested and, as a result, Practice Plus Group considers it to be robust and fit for purpose regardless of the”

    Source location

    Response from Practice Plus Group
    Page 3 · response
    Published 12 March 2026

    Open published response
  2. Dorset

    AI-generated summary

    Frazer Charlie Williams · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.

    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 process for recording and involving prisoners’ next of kin

    Wider context from the report

    “xiii. There is a lack of process regarding the recording of a prisoner’s next of kin and involvement of them at HMP Guys Marsh. ”

    Source location

    Frazer Charlie Williams · Prevention of Future Deaths report
    Page 7 · 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

    Establish a process for recording next-of-kin details and submitting them on NOMIS.

    Verbatim wording from the response

    “The Safety Team have recently addressed the process for recording details. OMU now identify the NOK and submit the information on NOMIS. In Frazer’s case he stated he had no NOK.”

    Source location

    Response from HMPPS / HMP Guys Marsh
    Page 4 · response
    Published 6 June 2024

    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

    Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.

    Verbatim wording from the response

    “With regard to the other concerns you have raised around a lack of national guidance relating to a range of healthcare issues in prison settings; operational issues regarding the ACCT process and engagement with prisoners’ family members, I would expect the other recipients of your report to address these in their responses, as they are responsible for matters relating to day to day operations within prison settings. I look forward to seeing their responses and working with them where appropriate, to avoid a repetition of the horrific events of this case.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 6 June 2024

    Open published response
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Data last updated 7 September 2026