Recurring concern

Inadequate medical assessment and escalation for unwell prisoners

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First reported 10 Dec 2014•Latest report 24 Mar 2026

Definition

What this concern includes

Includes failures in prison arrangements for recognising and medically assessing unwell prisoners and escalating their care, including seeking appropriate medical advice, conducting robust clinical assessments, using required deterioration-monitoring systems, arranging medical review and maintaining safety-netting.

Not included

Excludes generic prison staffing, leadership, training or communication deficiencies unless they directly impair medical assessment or escalation for an unwell prisoner.
Excludes custody supervision, welfare checks or observation failures that do not concern medical assessment or escalation of an unwell prisoner.
Excludes failures in non-prison healthcare settings unless the report explicitly supports the same prison medical-assessment and escalation concern.
Excludes failures limited to treatment after an appropriate medical assessment and escalation has already occurred.

Reports: 14
Individual concerns: 22
Date range: 2014–2026
Stated actions: 40

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 Service3

Ministry of Justice3

Department of Health and Social Care2

Nottinghamshire Healthcare NHS Foundation Trust2

Recipient name withheld2

The Phoenix Partnership (Leeds) Ltd2

Bedford Prison1

Birmingham and Solihull Mental Health NHS Foundation Trust1

Central and North West London NHS Foundation Trust1

Government Legal Department1

Herefordshire and Worcestershire Health and Care NHS Trust1

HM Inspectorate of Prisons1

Midlands Partnership University NHS Foundation Trust1

NHS England1

Northamptonshire Healthcare NHS Foundation Trust1

Concerns and responses across reports

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

24 Mar2026
Milton Keynes
Concerns raised1
1. Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances
This report raised 15 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 6
1. Action
  Clarify clinical roles and expectations and strengthen addictions-team governance through additional referral-timeliness and escalation audits.
  Stated by Central and North West London NHS Foundation TrustStated completed
2. Action
  Develop and implement the SPICE policy and local operating procedure for assessing and managing intoxication.
  Stated by Central and North West London NHS Foundation TrustStated completed
3. Action
  Introduce risk-based triage to prioritise prisoners at highest risk.
  Stated by Central and North West London NHS Foundation TrustStated completed
1. Action
  Refer intoxicated prisoners to the addictions team for review within 48 hours.
  Stated by Central and North West London NHS Foundation TrustStated in progress
2. Action
  Provide structured assessment tools, escalation expectations and clinical leadership to improve recognition and response to synthetic-cannabinoid deterioration.
  Stated by Central and North West London NHS Foundation TrustStated completed
3. Action
  Train clinical staff to recognise deterioration using NEWS2 and reinforce escalation pathways across services.
  Stated by Central and North West London NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Healthcare services alone cannot mitigate all risks within custody.
  Stated by Central and North West London NHS Foundation TrustUnable to act
AI-generated summary

Ronald William MEIKLE · 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

Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.

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
Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances
Wider context from the report
“Concern 2: Failure consistently to identify, record and respond to prisoners under the influence The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes. There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up. The head of service had an understanding of the drug under the influence policy that was starkly different to the written document. There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised. I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention. ”
Source location
Ronald William MEIKLE · 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
Clarify clinical roles and expectations and strengthen addictions-team governance through additional referral-timeliness and escalation audits.

Verbatim wording from the response
“Concern 2: Identification, recording and response to prisoners under the influence: We have clarified clinical roles and expectations, strengthened governance, and introduced additional audit measures within the addictions team to monitor referral timeliness and escalation. We have jointly developed a ‘SPICE’ policy and local operating procedure (LOP) that provides clear clinical guidance for assessing and managing intoxication. We have introduced a new risk-based triage model that”

Source location
Response from Central & North West London NHS Foundation Trust
Page 1 · response
Published 26 March 2026
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 implement the SPICE policy and local operating procedure for assessing and managing intoxication.

Verbatim wording from the response
“Concern 2: Identification, recording and response to prisoners under the influence: We have clarified clinical roles and expectations, strengthened governance, and introduced additional audit measures within the addictions team to monitor referral timeliness and escalation. We have jointly developed a ‘SPICE’ policy and local operating procedure (LOP) that provides clear clinical guidance for assessing and managing intoxication. We have introduced a new risk-based triage model that”

Source location
Response from Central & North West London NHS Foundation Trust
Page 1 · response
Published 26 March 2026
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
Introduce risk-based triage to prioritise prisoners at highest risk.

Verbatim wording from the response
“Concern 2: Identification, recording and response to prisoners under the influence: We have clarified clinical roles and expectations, strengthened governance, and introduced additional audit measures within the addictions team to monitor referral timeliness and escalation. We have jointly developed a ‘SPICE’ policy and local operating procedure (LOP) that provides clear clinical guidance for assessing and managing intoxication. We have introduced a new risk-based triage model that”

Source location
Response from Central & North West London NHS Foundation Trust
Page 1 · response
Published 26 March 2026
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
Refer intoxicated prisoners to the addictions team for review within 48 hours.

Verbatim wording from the response
“identifies and prioritises individuals at highest risk. Intoxicated prisoners are being immediately referred to the addictions team for review within 48 hours.”

Source location
Response from Central & North West London NHS Foundation Trust
Page 2 · response
Published 26 March 2026
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
Provide structured assessment tools, escalation expectations and clinical leadership to improve recognition and response to synthetic-cannabinoid deterioration.

Verbatim wording from the response
“Concern 9: Emergency response to suspected synthetic cannabinoid collapse We have improved staff capability to recognise deterioration linked to synthetic cannabinoid use by providing structured assessment tools, clear escalation expectations, and more visible clinical leadership. All CNWL clinical staff receive training in recognising deterioration using the NEWS2 protocol, and we have reinforced clear escalation pathways across our services, ensuring every clinician understands how and when to escalate concerns. We actively participate in joint simulation exercises and contribute to prison-led first aid and emergency response”

Source location
Response from Central & North West London NHS Foundation Trust
Page 2 · response
Published 26 March 2026
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
Train clinical staff to recognise deterioration using NEWS2 and reinforce escalation pathways across services.

Verbatim wording from the response
“Concern 9: Emergency response to suspected synthetic cannabinoid collapse We have improved staff capability to recognise deterioration linked to synthetic cannabinoid use by providing structured assessment tools, clear escalation expectations, and more visible clinical leadership. All CNWL clinical staff receive training in recognising deterioration using the NEWS2 protocol, and we have reinforced clear escalation pathways across our services, ensuring every clinician understands how and when to escalate concerns. We actively participate in joint simulation exercises and contribute to prison-led first aid and emergency response”

Source location
Response from Central & North West London NHS Foundation Trust
Page 2 · response
Published 26 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
Healthcare services alone cannot mitigate all risks within custody.

Verbatim wording from the response
“Thank you for bringing your concerns to our attention. While healthcare services alone cannot mitigate all risks within custody, the Trust is committed to learning from Mr Meikle’s death and to strengthening how vulnerability is identified and responded to across Health and Justice services. Should you have any questions or comments, please do not hesitate to contact me.”

Source location
Response from Central & North West London NHS Foundation Trust
Page 3 · response
Published 26 March 2026
Open published response
10 Mar2026
Worcestershire
Concerns raised1
1. Failure to consider hospital transfer for prisoners severely weakened by weight loss
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.
Respondent positions 2
1. Position
  Practice Plus Group is responsible for responding to concerns about healthcare delivery at HMP Hewell.
  Stated by HM Prison and Probation ServiceRedirects responsibility
1. Position
  The food and fluid refusal pathway is considered robust and fit for purpose regardless of the reason for refusal.
  Stated by Practice Plus GroupExisting arrangements considered sufficient
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 consider hospital transfer for prisoners severely weakened by weight loss
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 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
Practice Plus Group is responsible for responding to concerns about healthcare delivery at HMP Hewell.

Verbatim wording from the response
“Following evidence heard at the inquest you raised concerns directed to both HMPPS and Practice Plus Group (PPG). I understand PPG will respond to those issues relating to the delivery of healthcare at HMP Hewell, for which they are responsible. I am therefore responding to the issue relating to HMPPS.”

Source location
Response from HM Prison & Probation Service
Page 1 · 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
17 Feb2026
Bedfordshire and Luton
Concerns raised3
1. Failure to recognise and escalate clinical deterioration
2. Failure to align policies and protocols for managing prisoners suspected to be under the influence of illicit substances
3. Failure to arrange follow-up medical assessment when a prisoner's condition is not improving
This report raised 2 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
  Agree and implement a common local protocol, including a flowchart, defining healthcare and prison staff roles, responsibilities, escalation and management of suspected illicit-substance influence.
  Stated by Northamptonshire Healthcare NHS Foundation TrustStated completed
2. Action
  Facilitate mandatory induction training for healthcare staff on detecting and managing suspected illicit-substance influence.
  Stated by Northamptonshire Healthcare NHS Foundation TrustStated in progress
3. Action
  Implement a single agreed UTI protocol standardising responsibilities, observations, escalation routes and handover expectations.
  Stated by HM Prison and Probation ServiceStated completed
1. Action
  Provide staff guidance on recognising UTI signs, initiating the protocol, completing observations and undertaking follow-up checks.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Assure documentation and observations, record improvement needs, and escalate issues concerning timescales or procedures to senior leaders.
  Stated by HM Prison and Probation ServiceStated completed
AI-generated summary

Edward James HANDS · 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

Edward James Hands, known as Eddie, died in his cell at HMP Bedford on 16 February 2024 after consuming methadone and developing aspiration pneumonitis. The inquest identified failures in follow-up care, monitoring, escalation, and the implementation of the Under the Influence protocol, with confusion between prison and healthcare staff about their responsibilities.

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 recognise and escalate clinical deterioration
Wider context from the report
“The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. ”
Source location
Edward James HANDS · 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
Failure to align policies and protocols for managing prisoners suspected to be under the influence of illicit substances
Wider context from the report
“The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. ”
Source location
Edward James HANDS · 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
Failure to arrange follow-up medical assessment when a prisoner's condition is not improving
Wider context from the report
“The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. ”
Source location
Edward James HANDS · 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
Agree and implement a common local protocol, including a flowchart, defining healthcare and prison staff roles, responsibilities, escalation and management of suspected illicit-substance influence.

Verbatim wording from the response
“We have worked with the Prison Governor and Head of Safety to agree and implement a common, local protocol for managing those suspected to be under the influence of illicit substances (UTI) at HMP Bedford. I have enclosed a copy of the protocol with this letter for your information.”

Source location
Response from Northamptonshire Healthcare NHS Foundation Trust
Page 2 · response
Published 23 February 2026
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
Facilitate mandatory induction training for healthcare staff on detecting and managing suspected illicit-substance influence.

Verbatim wording from the response
“The healthcare and prison service leadership teams circulated the UTI protocol and an amended UTI recording log to staff late last year. Mandatory training for healthcare staff on UTI detection and management is being facilitated by the Trust’s Resuscitation Lead and is part of our induction programme. An ‘Airways Champion’ has also been identified. The Airways Champion supports our leadership team in maintaining competence in airway management and suction machine use. They will also help deliver future UTI simulation training sessions.”

Source location
Response from Northamptonshire Healthcare NHS Foundation Trust
Page 2 · response
Published 23 February 2026
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 a single agreed UTI protocol standardising responsibilities, observations, escalation routes and handover expectations.

Verbatim wording from the response
“Following the conclusion of the inquest HMP Bedford and NHFT carried out a joint review of the UTI policies and protocols in place. This review resulted in the removal of any previous conflicting guidance and implementation of a single UTI protocol with standardisation of responsibilities, including observation requirements, escalation routes, and handover expectations. This protocol has been agreed by both parties and is to be followed by both operational and healthcare staff at HMP Bedford.”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 23 February 2026
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
Provide staff guidance on recognising UTI signs, initiating the protocol, completing observations and undertaking follow-up checks.

Verbatim wording from the response
“• Staff have been given guidance on recognising signs of being UTI, initiating the protocol, completing observations, and ensuring follow up checks are undertaken.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 23 February 2026
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
Assure documentation and observations, record improvement needs, and escalate issues concerning timescales or procedures to senior leaders.

Verbatim wording from the response
“• Assurance of documentation and observations is completed to ensure compliance of timescales and escalation procedures. Where this identifies areas requiring improvement a record is made and the issue escalated to both prison and healthcare senior leaders to be addressed as appropriate.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 23 February 2026
Open published response
7 Oct2024
Mid Kent and Medway
Concerns raised1
1. Lack of a concrete escalation route for prison healthcare staff challenging the appropriateness and sustainability of acute-setting discharge
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.

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

John Raymond EYRE · 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 Raymond Eyre was a serving prisoner whose health deteriorated in 2022, including recurrent neutropenic sepsis, and he died in hospital on 20 November 2022 from pneumonia, with liver disease also recorded. Concerns included the lack of a concrete escalation route when prison healthcare staff challenged his discharge and the absence of national guidance on returning a prisoner to custody when those concerns had not been considered by the consultant.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a concrete escalation route for prison healthcare staff challenging the appropriateness and sustainability of acute-setting discharge
Wider context from the report
“(1) There was no concrete escalation route when prison healthcare staff challenged the appropriateness and sustainability of discharge from the acute setting. ”
Source location
John Raymond EYRE · Prevention of Future Deaths report
Page 3 · concerns
Open source report
19 Jul2024
Mid Kent and Medway
Concerns raised2
1. Lack of guidance for escalating and monitoring suspected intoxication
2. Reliance on untrained OSG officers to decide whether to monitor or escalate suspected intoxication
This report raised 5 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
  Review out-of-hours GP calls to assess their frequency and effectiveness.
  Stated by Oxleas NHS Foundation TrustStated planned
2. Action
  Update guidance to clarify that required patient monitoring cannot occur without on-site healthcare and requires hospital transfer.
  Stated by Oxleas NHS Foundation TrustStated planned
3. Action
  Issue and implement a night-state process for escalating suspected illicit-substance cases, conducting welfare checks, deciding on medical escalation, and recording follow-up requirements.
  Stated by HM Prison and Probation ServiceStated completed
1. Action
  Develop national guidance for staff managing prisoners suspected to be under the influence of illicit substances and complete stakeholder consultation.
  Stated by HM Prison and Probation ServiceStated in progress
2. Action
  Roll out agreed national guidance through regional and local leads, support local guidance development, and conduct assurance checks on its development and embedding.
  Stated by HM Prison and Probation ServiceStated planned
Respondent positions 2
1. Position
  Existing night arrangements, including trained officers, personal management plans, on-call GP advice and emergency services, are relied upon to manage healthcare concerns.
  Stated by Oxleas NHS Foundation TrustExisting arrangements considered sufficient
1. Position
  Patient monitoring cannot be undertaken at night without healthcare staff on site; patients requiring monitoring must instead be transferred to hospital.
  Stated by Oxleas NHS Foundation TrustUnable to act
AI-generated summary

Benjamin Noah Frances Harrison · 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

Benjamin Harrison died in HMP Rochester on 9 May 2022 after inhaling fumes from a medication heated with a vape pen. The inquest identified concerns including insufficient overnight healthcare cover, failure to inform the night orderly that he appeared to be under the influence, inadequate guidance for monitoring and escalation, and weaknesses in medication briefing and information sharing.

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 guidance for escalating and monitoring suspected intoxication
Wider context from the report
“(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester. During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state. OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter. The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented. Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice. ”
Source location
Benjamin Noah Frances Harrison · Prevention of Future Deaths report
Page 3 · 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
Reliance on untrained OSG officers to decide whether to monitor or escalate suspected intoxication
Wider context from the report
“(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester. During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state. OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter. The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented. Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice. ”
Source location
Benjamin Noah Frances Harrison · 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
Review out-of-hours GP calls to assess their frequency and effectiveness.

Verbatim wording from the response
“The agreed arrangements between the hours of 21:00 – 07:30 when there is no commissioned healthcare provision on site, is that all higher risk prisoners have an agreed personal management plan in accordance with the Personal Management Plan Local Operating Procedure, and that in the event that officers have any healthcare concerns regarding a prisoner the Custodial Manager in charge of the prison should call the On-Call GP for further advice and guidance, and in an emergency they should dial 999 for emergency services. A review of out of hours calls to the out of hours GP service will be carried out in Autumn 2024 to ascertain frequency and effectiveness of use. Any calls to out of hours GP are discussed in the Governor’s morning briefing each day and followed up by the healthcare team.”

Source location
Response from Oxleas NHS Foundation Trust
Page 3 · response
Published 1 August 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
Update guidance to clarify that required patient monitoring cannot occur without on-site healthcare and requires hospital transfer.

Verbatim wording from the response
“We will ensure that this guidance is updated and that it also includes the relevant information to manage the expectations of HMPPS colleagues – for example if any patient monitoring is required then this cannot be undertaken at HMP Rochester when there are no healthcare staff on site and in any circumstances where a patient requires monitoring then they would need to be transferred to hospital.”

Source location
Response from Oxleas NHS Foundation Trust
Page 4 · response
Published 1 August 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
Issue and implement a night-state process for escalating suspected illicit-substance cases, conducting welfare checks, deciding on medical escalation, and recording follow-up requirements.

Verbatim wording from the response
“You have expressed concern that there does not appear to be a clear process at HMP Rochester for escalating concerns when prisoners appear to be under the influence of an illicit substance outside of the hours in which healthcare staff are present. I have received assurance from the Governor of HMP Rochester that following the inquest an order has been issued to all staff setting out that at times when there is no on-site healthcare team, such as during the night state, prison staff must escalate concerns about prisoners suspected to be under the influence of illicit substances to the Orderly Officer. The Orderly Officer will then attend to conduct a welfare check on the prisoner.”

Source location
Response from HMPPS
Page 1 · response
Published 1 August 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 national guidance for staff managing prisoners suspected to be under the influence of illicit substances and complete stakeholder consultation.

Verbatim wording from the response
“HMPPS is currently developing national guidance for all staff managing prisoners who are under the influence of illicit substances. The guidance has been developed by the national Substance Misuse Group with contributions from internal and external stakeholders, including from areas such as health and safety. Its purpose is to provide structured guidance for prisons to support the development of local under the influence guidance that will ensure that there is a consistent and safe response to the management of prisoners. It is important to note that this guidance does not replace healthcare advice and in a medical emergency instructions and advice from healthcare colleagues must be followed as a priority.”

Source location
Response from HMPPS
Page 2 · response
Published 1 August 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
Roll out agreed national guidance through regional and local leads, support local guidance development, and conduct assurance checks on its development and embedding.

Verbatim wording from the response
“Once agreed, the guidance document will be rolled out via the regional and local drug strategy leads who will be responsible for developing local guidance. The Substance Misuse Group will deliver additional training and support if necessary, and through their rolling programme of support assurance checks will be conducted to ensure that under the influence guidance has been developed and embedded at each prison.”

Source location
Response from HMPPS
Page 2 · response
Published 1 August 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
Existing night arrangements, including trained officers, personal management plans, on-call GP advice and emergency services, are relied upon to manage healthcare concerns.

Verbatim wording from the response
“OSG officers have undergone basic first aid training during their induction to the standard deemed by HMPPS appropriate for their roles, including being in service during night patrols without healthcare staff on site, and managing any situation which may occur. HMPPS colleagues will be able to give further details regarding this training. The OSGs work together with Orderly Officers who have additional training and experience, and they have operational procedures to follow in the event of prisoners who present as requiring medical support during night state.”

Source location
Response from Oxleas NHS Foundation Trust
Page 3 · response
Published 1 August 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
Patient monitoring cannot be undertaken at night without healthcare staff on site; patients requiring monitoring must instead be transferred to hospital.

Verbatim wording from the response
“As stated, there is no in-house healthcare in HMP Rochester after 9pm. There are arrangements for GP on-call provision arranged by providers which we have in place at HMP Rochester. GPs on an on-call rota have access to SystmOne records and therefore access to past medical history, past and current medical problems and any future appointments is in place to provide medical advice to prison staff, prevent unnecessary transfers to hospital and ensure patient safety by providing guidance on next steps when hospital transfer is required.”

Source location
Response from Oxleas NHS Foundation Trust
Page 4 · response
Published 1 August 2024
Open published response
17 Jan2024
Nottinghamshire
Concerns raised1
1. Failure to follow the Under the Influence Policy
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Change senior managers and officers as part of ongoing efforts to address failures in observations and compliance with the Under the Influence Policy.
  Stated by SodexoStated in progress
AI-generated summary

Kane Christopher Boyce · 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

Kane Christopher Boyce, a serving prisoner at HMP Lowdham Grange, was found with a ligature around his neck on 3 October 2021 and could not be resuscitated. The jury found that alcohol intoxication and the failure of staff to share information, open an under-the-influence log, adequately monitor him, and consider risk when isolating cell power and ignoring cell bells contributed to his death. The report raised concerns about these practices, staff understanding of relevant policies, learning from deaths in custody, and organisational candour.

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 follow the Under the Influence Policy
Wider context from the report
“3. Failure to follow the local Under the Influence Policy Three members of staff suspected Kane was under the influence of something in the hours before his death, yet none opened an under the influence log or sought any medical advice about how frequently to check on him, what signs of deterioration to look out for, and when to seek further assistance. ”
Source location
Kane Christopher Boyce · 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
Change senior managers and officers as part of ongoing efforts to address failures in observations and compliance with the Under the Influence Policy.

Verbatim wording from the response
“Sodexo have concerns about the practices of the staff that transferred to Sodexo with HMP Lowdham Grange. These include failures of staff to conduct observations and follow the Under the Influence Policy. This is part of an ongoing culture change that we are trying to address but one that takes time and has to date involved changes to Senior Managers and Officers at the prison.”

Source location
Response from Sodexo
Page 2 · response
Published 25 January 2024
Open published response
4 Jan2024
East Sussex
Concerns raised2
1. Failure by healthcare staff to escalate sick prisoners’ cases
2. Failure by healthcare staff to properly assess a sick prisoner’s condition
This report raised 10 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

Stephen COSTER · 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

Stephen Coster died from meningoencephalitis owing to Streptococcus pneumoniae after becoming seriously unwell while detained at HMP Lewes. The inquest found delays in providing treatment and transferring him to hospital, with concerns including inadequate observations and assessment, poor record keeping, failures to escalate, and breakdowns in communication and leadership between prison and healthcare staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure by healthcare staff to escalate sick prisoners’ cases
Wider context from the report
“b. A failure by healthcare staff to carry out adequate observations and to properly assess Stephen Coster’s condition as well as a failure to escalate his case. ”
Source location
Stephen COSTER · 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
Failure by healthcare staff to properly assess a sick prisoner’s condition
Wider context from the report
“b. A failure by healthcare staff to carry out adequate observations and to properly assess Stephen Coster’s condition as well as a failure to escalate his case. ”
Source location
Stephen COSTER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
7 Jul2023
Nottinghamshire
Concerns raised2
1. Failure to use NEWS2 monitoring for acutely unwell prisoners
2. Lack of robust GP clinical assessments for prisoners
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.
Actions described in response 4
1. Action
  Provide dedicated Resus Lead support, onsite training, scenario coaching, code-call shadowing and feedback for deteriorating-patient care.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
2. Action
  Make NEWS2 training available online and incorporate the NEWS2, sepsis and SBAR package into monthly induction for new starters.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
3. Action
  Develop and operate a NEWS2 audit programme, compile recommendations and feed findings into governance and dissemination.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
1. Action
  Amend the Sysmone Unit to make recording NEWS2 observations easier for staff.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
AI-generated summary

Christopher Howard SMITH · 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

Christopher Howard Smith was a serving prisoner at HMP Lowdham Grange who died at Queen’s Medical Centre on 19 May 2019 from cardiac arrest due to a massive pulmonary embolism, predisposed by deep vein thrombosis. The report describes progressive deterioration, inadequate monitoring and clinical assessment, delayed escalation and ambulance transfer, and failures in communication and care. It also identifies concerns about unsafe clinical-care practices, inadequate record keeping and disclosure, and a lack of candour in post-death investigations.

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 use NEWS2 monitoring for acutely unwell prisoners
Wider context from the report
“1. An inability to provide prisoners at HMP Lowdham Grange with safe clinical care I heard evidence, and the jury reached findings, that there was an unsafe practice of staff conducting important healthcare and wellbeing observations via the cell door observation hatch. Observing an unwell prisoner through a hatch slightly larger than a letterbox undermines the safety of the clinical assessment. Healthcare staff did not utilise the NEWS2 system of monitoring the condition of an acutely unwell prisoner, despite the Trust having adopted this recognised healthcare tool many years prior. The Forensic Directorate has continued to lag behind other areas of the Trust where NEWS2 is fully embedded and this has previously been identified as an issue linked to other deaths. There was a lack of robust GP visits, despite such being mandated by the Prison Rules. When visits did take place, they were often via the cell door observation hatch and conducted as “fleeting glances” rather than robust clinical assessments. Again, this is unsafe. There was a lack of effective leadership of the healthcare department to ensure that staff had created a safe plan of care for Christopher. Senior personnel were not aware of Christopher’s week-long deterioration in the segregation unit until very late in the chronology of events, nor were they aware of a dispute between the mental health and physical health teams as to the differential diagnoses that might be causing his concerning symptoms and deterioration. Despite daily lunch time meetings, there was a stark lack of professional curiosity from senior staff as to the plan of care for Christopher and what safety netting, if any, was in place. ”
Source location
Christopher Howard SMITH · Prevention of Future Deaths report
Page 3 · 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 robust GP clinical assessments for prisoners
Wider context from the report
“1. An inability to provide prisoners at HMP Lowdham Grange with safe clinical care I heard evidence, and the jury reached findings, that there was an unsafe practice of staff conducting important healthcare and wellbeing observations via the cell door observation hatch. Observing an unwell prisoner through a hatch slightly larger than a letterbox undermines the safety of the clinical assessment. Healthcare staff did not utilise the NEWS2 system of monitoring the condition of an acutely unwell prisoner, despite the Trust having adopted this recognised healthcare tool many years prior. The Forensic Directorate has continued to lag behind other areas of the Trust where NEWS2 is fully embedded and this has previously been identified as an issue linked to other deaths. There was a lack of robust GP visits, despite such being mandated by the Prison Rules. When visits did take place, they were often via the cell door observation hatch and conducted as “fleeting glances” rather than robust clinical assessments. Again, this is unsafe. There was a lack of effective leadership of the healthcare department to ensure that staff had created a safe plan of care for Christopher. Senior personnel were not aware of Christopher’s week-long deterioration in the segregation unit until very late in the chronology of events, nor were they aware of a dispute between the mental health and physical health teams as to the differential diagnoses that might be causing his concerning symptoms and deterioration. Despite daily lunch time meetings, there was a stark lack of professional curiosity from senior staff as to the plan of care for Christopher and what safety netting, if any, was in place. ”
Source location
Christopher Howard SMITH · 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
Provide dedicated Resus Lead support, onsite training, scenario coaching, code-call shadowing and feedback for deteriorating-patient care.

Verbatim wording from the response
“As a result of identifying a need to develop a training programme and approach that would ensure our staff have a greater understanding of NEWS 2 and the application of NEWS2 in a patient setting, a number of actions have been undertaken in order to address this:”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 1 · response
Published 6 November 2023
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
Make NEWS2 training available online and incorporate the NEWS2, sepsis and SBAR package into monthly induction for new starters.

Verbatim wording from the response
“• Additionally, training has been made available online to provide ease of access for staff members.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 2 · response
Published 6 November 2023
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 operate a NEWS2 audit programme, compile recommendations and feed findings into governance and dissemination.

Verbatim wording from the response
“• Development of an audit programme relating to NEWS2, latest audit undertaken in August 2023, report and recommendations being compiled which will feed into internal governance infrastructures and be disseminated.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 2 · response
Published 6 November 2023
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
Amend the Sysmone Unit to make recording NEWS2 observations easier for staff.

Verbatim wording from the response
“• Amendments have been made to the Sysmone Unit to ensure it is easier for staff to capture and record observations relating to NEWS2.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 2 · response
Published 6 November 2023
Open published response
15 Mar2023
Birmingham and Solihull
Concerns raised1
1. Failure to identify the need for inpatient admission and assessment for secure transfer
This report raised 10 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

Jai SINGH · 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

Jai Singh died at City Hospital on 28 January 2022 after being found in cardiac arrest in his cell at HMP Birmingham, having asphyxiated after placing a bag over his head. The report identifies repeated failures to communicate and record family and clinical concerns, use interpreters, assess risk, operate the ACCT process, and provide appropriate mental-health admission and transfer. It also identifies ongoing risks from the absence of a psychiatrist in the prison mental-health MDT and the lack of ongoing risk-assessment documentation in SystemOne.

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 identify the need for inpatient admission and assessment for secure transfer
Wider context from the report
“2. Much of the evidence at the inquest focused on the central issue of repeated missed opportunities to identify that Mr. Singh required admission to the prison's inpatient ward, ward 2, and assessment for section 48 transfer to a medium secure unit (which would have been likely to result in transfer to a medium secure unit). The consequences of the failure to transfer Mr. Singh to an inpatient setting were compounded by the fact that he was not taken onto the mental health team's caseload promptly and therefore did not have the benefit of an allocated CPN and the oversight and input of a mental health multi-disciplinary team. Many steps have been undertaken by Birmingham and Solihull Mental Health Trust (who provide mental health services within the prison) to minimise the risk of such a situation occurring again. ”
Source location
Jai SINGH · Prevention of Future Deaths report
Page 3 · concerns
Open source report
20 Dec2022
Nottinghamshire
Concerns raised2
1. Failure to consistently apply NEWS2 assessment and monitoring, supported by adequate training and guidance
2. Absence of an agreed joint care plan for acutely unwell prisoners remaining in prison
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 13
1. Action
  Email Offender Health staff the report findings and NEWS2 failure information.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
2. Action
  Monitor NEWS2 training completion through weekly communications, compliance updates and exception reporting.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
3. Action
  Align essential NEWS2 and physical healthcare training with practical NEWS2 requirements.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
1. Action
  Circulate the NEWS2 and sepsis training tool to sites for delivery during continuing professional development sessions.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
2. Action
  Distribute NEWS2 flashcards and paper templates across sites as emergency-response aids and working documents.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
3. Action
  Assess staff understanding of the NEWS2 toolkit through essential training.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
4. Action
  Assess NEWS2 competency at all sites through Clinical Lead visits and provide additional support or training where required.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
5. Action
  Develop a regular NEWS2 competency-assessment and support model for Offender Health teams.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
6. Action
  Complete a training gap analysis to identify critical training needs for Offender Health healthcare staff.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
7. Action
  Develop a rolling 12-month Offender Health training programme addressing identified critical topics.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
8. Action
  Update and recirculate the joint urgent-assessment protocol for deteriorating patients, including emergency and code-response procedures.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
9. Action
  Deliver joint prison and healthcare training to promote collaborative planning for prisoners with acute illnesses.
  Stated by HM Prison and Probation ServiceStated completed
10. Action
  Hold weekly Safety Intervention Meetings chaired by the Head of Safer Custody to identify and discuss acutely unwell or at-risk prisoners and agree their care and support.
  Stated by HM Prison and Probation ServiceStated completed
AI-generated summary

Alexander Michael BRAUND · 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

Alexander Michael Braund was a 25-year-old remand prisoner at HMP Nottingham who became acutely unwell with an undetected atypical pneumonia and died on 10 March 2020 after cardiac arrest and withdrawal of life support. The principal concerns included failures in NEWS2 assessment and monitoring, the absence of a joint healthcare and prison-staff care plan, delays in entering his cell and calling a medical emergency code, and potential weaknesses in the integrity of amended electronic medical records.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to consistently apply NEWS2 assessment and monitoring, supported by adequate training and guidance
Wider context from the report
“1.(HEALTHCARE) Lack of safe system, supported by training, guidance, and compliance auditing, for the provision of physical healthcare assessment and monitoring by NEWS2 for acutely unwell patients in a secure setting. The Jury found shortcomings in the healthcare afforded to Alex at HMP Nottingham in the form of "continuous failures to provide adequate healthcare, which probably more than minimally contributed to his death". I heard evidence that staff were not consistently assessing acutely unwell patients using the NEWS2 system, despite the scoring system having been adopted across the NHS over the past decade and having been adopted by this Trust many years prior. In 2017, when relaunching the NEWS system, the Royal College of Physicians noted, "Every so often, someone comes up with an idea that is so obvious, no one can understand why it wasn’t thought of before. I am proud that the RCP’s National Early Warning Score (NEWS) is one of those initiatives – not just a chart (or iPad) at the end of the bed to record the patient’s physical signs and symptoms, but the chart at the end of the bed – a single point of truth to unify recording of symptoms across the NHS, consolidate training for doctors and nurses in the recording of symptoms, and thereby improve patient safety. When the RCP launched the NEWS in 2012, we hoped to see the score adopted across the NHS. What has been more astonishing is the adoption of the score internationally, with requests to use NEWS coming from health services across the world from Europe to India and the USA, including the US Naval Air Forces!" I heard evidence of an inconsistent application of NEWS2 by staff, an inconsistent awareness of NEWS2 across the staff body, and an absence of clear and robust training supported by guidance, ensuring staff were aware of the expectations of their employer with regards to the use of NEWS2 in monitoring acutely unwell patients. Sadly, Alex’s is not an isolated case. I have been repeatedly assured at a senior level from Nottinghamshire Healthcare NHS Foundation Trust that they are seeking to embed NEWS2 across their Directorates, yet successive inquests have heard of patients failed by the lack of use of the system by the clinical staff responsible for their medical care. If this issue is not addressed across the Trust, with sufficient urgency, patients will continue to die in Trust settings due to a failure to recognise the deteriorating patient, and to arrange for timely healthcare intervention. Further, I heard evidence that the newly implemented compliance audit plans for NEWS2 are not safe or robust because the audit is limited to monitoring the emergency review template on Systmone, which staff are routinely failing to utilise, instead preferring to add free text entries to the running record, which cannot be audited with ease. If the Trust is incapable of monitoring compliance with the initiative, there will be repeated missed opportunities to provide support and guidance to Directorates, wards or individual staff who are deviating from expected practice with regards to NEWS2. ”
Source location
Alexander Michael BRAUND · 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
Absence of an agreed joint care plan for acutely unwell prisoners remaining in prison
Wider context from the report
“2. (HEALTHCARE AND HMP) The absence of a safe joint system of care (between discipline and healthcare staff) for supporting and managing acutely unwell patients who remain in the prison setting, rather than being transferred to a dedicated healthcare facility. The very nature of incarceration curtails the prisoner’s free movement and ready access to healthcare. Instead, their incarceration places them wholly reliant on the communication between discipline staff on the wing, and healthcare staff available elsewhere within the setting, to obtain timely healthcare assessment and monitoring. I heard evidence that Alex had been told to "press his cell bell" if he "felt worse". Both Alex and his cell mate did so repeatedly between 9 and 10 March 2020, with varying degrees of success regarding healthcare attendance at his cell. Despite discipline and healthcare staff knowing that Alex was suffering with an acute illness, and in the knowledge that there was no plan for him to be transferred to a hospital, there was an absence of agreed joint plan between health and discipline staff as to how often Alex would be seen by each profession, what constitutes a deterioration for him, and what to do in the event of such a deterioration, to seek to detect and manage his risk of physical healthcare deterioration. In contrast, in circumstances whereby a prisoner is thought to be at risk of self-harm or suicide, there is an agreed joint care planning system (ACCT Version 6) which sets out the clear expectations placed on each profession to seek to keep the prisoner safe (enshrined in Prison Service Instruction). There is no such equivalent system in operation nationally with regards to the risk of physical healthcare deterioration, but that does not absolve each service from ensuring acutely unwell patients are kept safe by way of robust joint local care planning. If acutely unwell patients continue to be managed in the prison setting without an agreed joint plan of care between health and discipline staff, deaths will continue to occur in these circumstances. ”
Source location
Alexander Michael BRAUND · 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
Email Offender Health staff the report findings and NEWS2 failure information.

Verbatim wording from the response
“Subsequent to receiving the Regulation 28 Report on 21st December 2022, all Trust employees of Offender Health were emailed in regard to the findings and in particular the outcome of NEWS2 failures.”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 1 · response
Published 4 January 2023
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
Monitor NEWS2 training completion through weekly communications, compliance updates and exception reporting.

Verbatim wording from the response
“In the first instance employees were requested to ensure they had completed the online training by 31st December 2022. To date, as of 13th February 2023, across the Offender Health Directorate we have achieved 86% in relation to staff who have completed the training. This is for those staff currently working and not absent.”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 2 · response
Published 4 January 2023
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
Align essential NEWS2 and physical healthcare training with practical NEWS2 requirements.

Verbatim wording from the response
“Following this, the Heads of Healthcare have weekly communication to all employees to ensure they have undertaken the training, with audits in place to monitor compliance. To support this process of monitoring training, Heads of Healthcare are provided with weekly updates on their teams’ compliance and a requirement to provide an exception report to the Divisional Management Team (DMT) for non-compliance. This will alert the DMT to any hot spot areas and identify where to dedicate further support to allow training. Nottinghamshire Healthcare NHS Foundation Trust Learning and Development Department are working closely with the Offender Health DMT to ensure essential training on NEWS2, and physical healthcare meets the requirements to teach staff how to use NEWS2 in practice.”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 2 · response
Published 4 January 2023
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
Circulate the NEWS2 and sepsis training tool to sites for delivery during continuing professional development sessions.

Verbatim wording from the response
“In addition, the Clinical Lead for Physical Healthcare has provided a training tool regarding NEWS2 and SEPSIS. This has been circulated to all sites for the clinical matrons to deliver this training during CPD sessions.”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 2 · response
Published 4 January 2023
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
Distribute NEWS2 flashcards and paper templates across sites as emergency-response aids and working documents.

Verbatim wording from the response
“To support Trust employees, a NEWS2 Flashcard and paper templates have been reviewed and distributed across all sites and will be available in all emergency response bags as an aide memoire and working documents (Appendix 2). This is to support ease of access and act as a reminder during emergency situations across the sites, communicating clear expectations and requirements for patient safety. The NEWS2 observation template is also clearly visible on the Clinical Tree and should link to the observations template within SystmOne.”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 2 · response
Published 4 January 2023
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
Assess staff understanding of the NEWS2 toolkit through essential training.

Verbatim wording from the response
“It is recognised that training alone is not sufficient to assess individuals’ learning and understanding of the toolkit and responses required for unwell patients. The Trust essential training will assess employees’ understanding of the News2 toolkit. In addition, Clinical Leads will be attending all sites on a rolling basis to assess competency of staff using NEWS2 and provide further support/ training where required. We are currently working with the wider Trust to look at how this can be delivered regularly to the all the teams across Offender Health.”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 2 · response
Published 4 January 2023
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
Assess NEWS2 competency at all sites through Clinical Lead visits and provide additional support or training where required.

Verbatim wording from the response
“It is recognised that training alone is not sufficient to assess individuals’ learning and understanding of the toolkit and responses required for unwell patients. The Trust essential training will assess employees’ understanding of the News2 toolkit. In addition, Clinical Leads will be attending all sites on a rolling basis to assess competency of staff using NEWS2 and provide further support/ training where required. We are currently working with the wider Trust to look at how this can be delivered regularly to the all the teams across Offender Health.”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 2 · response
Published 4 January 2023
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 regular NEWS2 competency-assessment and support model for Offender Health teams.

Verbatim wording from the response
“It is recognised that training alone is not sufficient to assess individuals’ learning and understanding of the toolkit and responses required for unwell patients. The Trust essential training will assess employees’ understanding of the News2 toolkit. In addition, Clinical Leads will be attending all sites on a rolling basis to assess competency of staff using NEWS2 and provide further support/ training where required. We are currently working with the wider Trust to look at how this can be delivered regularly to the all the teams across Offender Health.”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 2 · response
Published 4 January 2023
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
Complete a training gap analysis to identify critical training needs for Offender Health healthcare staff.

Verbatim wording from the response
“The Clinical Leads for Offender Health, alongside the Head of Nursing are currently undertaking a training gap analysis exercise with a view to identifying the critical training needs for all healthcare staff and develop a robust training programme for Offender Health on a rolling 12 monthly basis. This has been planned on Prison lockdown days and we have identified critical topics that need to be addressed including but not exhaustive, emergency response to NEWS2, Mental Capacity Record Keeping and Assessment, Care in Custody and Team work, Suicide and Self Harm training (Appendix 4).”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 3 · response
Published 4 January 2023
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 rolling 12-month Offender Health training programme addressing identified critical topics.

Verbatim wording from the response
“The Clinical Leads for Offender Health, alongside the Head of Nursing are currently undertaking a training gap analysis exercise with a view to identifying the critical training needs for all healthcare staff and develop a robust training programme for Offender Health on a rolling 12 monthly basis. This has been planned on Prison lockdown days and we have identified critical topics that need to be addressed including but not exhaustive, emergency response to NEWS2, Mental Capacity Record Keeping and Assessment, Care in Custody and Team work, Suicide and Self Harm training (Appendix 4).”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 3 · response
Published 4 January 2023
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
Update and recirculate the joint urgent-assessment protocol for deteriorating patients, including emergency and code-response procedures.

Verbatim wording from the response
“The joint protocol for the urgent assessment process for the deteriorating patient is to be updated and re-circulated to all prison and healthcare staff. This includes the PSO 1300 emergency response and the management of code red and code blue. Joint training is to be provided to Prison staff to ensure they are familiar with the process and are confident in its use.”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 5 · response
Published 4 January 2023
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
Deliver joint prison and healthcare training to promote collaborative planning for prisoners with acute illnesses.

Verbatim wording from the response
“The matter of concern raised for both HMPPS and Healthcare concerned the absence of a safe joint system of care (between discipline and healthcare staff) for supporting and managing acutely unwell patients who remain in the prison setting, rather than being transferred to a dedicated healthcare facility. I can confirm that the Head of Healthcare and the Governor of HMP Nottingham arranged a joint training event for all staff on 25 January 2023, designed to encourage a collaborative approach between prison and healthcare staff to achieve joined up planning of care for prisoners with acute illnesses. The Head of Safer Custody now chairs a weekly Safety Intervention Meeting at which prisoners who are acutely unwell or at risk of harm are identified and discussed, with prison and healthcare staff agreeing the care and support to be put in place in each case.”

Source location
Response from HM Prison and Probation Service
Page 2 · response
Published 4 January 2023
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
Hold weekly Safety Intervention Meetings chaired by the Head of Safer Custody to identify and discuss acutely unwell or at-risk prisoners and agree their care and support.

Verbatim wording from the response
“The matter of concern raised for both HMPPS and Healthcare concerned the absence of a safe joint system of care (between discipline and healthcare staff) for supporting and managing acutely unwell patients who remain in the prison setting, rather than being transferred to a dedicated healthcare facility. I can confirm that the Head of Healthcare and the Governor of HMP Nottingham arranged a joint training event for all staff on 25 January 2023, designed to encourage a collaborative approach between prison and healthcare staff to achieve joined up planning of care for prisoners with acute illnesses. The Head of Safer Custody now chairs a weekly Safety Intervention Meeting at which prisoners who are acutely unwell or at risk of harm are identified and discussed, with prison and healthcare staff agreeing the care and support to be put in place in each case.”

Source location
Response from HM Prison and Probation Service
Page 2 · response
Published 4 January 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances

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.6

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

Concerns raised1

Failure to consider hospital transfer for prisoners severely weakened by weight loss

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

Concerns raised3

Failure to recognise and escalate clinical deterioration

Failure to align policies and protocols for managing prisoners suspected to be under the influence of illicit substances

Failure to arrange follow-up medical assessment when a prisoner's condition is not improving

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 a concrete escalation route for prison healthcare staff challenging the appropriateness and sustainability of acute-setting discharge

Concerns raised2

Lack of guidance for escalating and monitoring suspected intoxication

Reliance on untrained OSG officers to decide whether to monitor or escalate suspected intoxication

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

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

Actions described in response 6

Respondent positions 1

Respondent positions 2

Actions described in response 5

Actions described in response 5

Respondent positions 2