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

Distinct published reports

Individual concerns
22

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
40

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.

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.

  1. Inner North London

    AI-generated summary

    Mr Khairul Rahman · Prevention of Future Deaths report

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

    Report summary

    Mr Khairul Rahman became unwell during a COVID-19 outbreak at HMP Pentonville, was later admitted to hospital, and died on 22 January 2021 from COVID-19. Concerns included inaccurate or non-contemporaneous documentation of clinical interactions, intervals between observations that did not align with the NEWS2 scoring system, reliance on prisoners to self-report deterioration, and the lack of a clear effective alternative system for monitoring in the prison healthcare setting.

    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 undertake further observations at intervals guided by the NEWS2 scoring system

    Wider context from the report

    “1. There does not seem to be a robust system in place in the prison healthcare setting for contemporaneous or accurate retrospective documentation of the timing of clinical interactions. I heard evidence and received a further statement, following the conclusion of the inquest, which set out the difficulties that the prison environment causes, in terms of being able to document accurately. However, I remain concerned that the lack of accurate documentation means that subsequent review of the appropriateness of clinical care, in particular, response times is hampered; 2. The interval to further observations being undertaken were not inline with the NEWS2 scoring system and, in oral evidence, it was set out that prisoners were expected to self-report deterioration. This differs from latter information, provided after the conclusion of the inquest. However, it remains a concern. The use of the NEWS2 scoring system remains unclear; the post-inquest information seemingly sets out both that this system was only to used after a positive COVID-19 result but also at daily handover. Whilst recognising that the prison environment differs from a hospital setting, I remain concerned that the care provided was not as guided by the NEWS2 scoring system and that no alternative system appears to be in place that can be used effectively in the prison healthcare setting. ”

    Source location

    Mr Khairul Rahman · 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

    Unclear use of the NEWS2 scoring system and absence of an effective alternative monitoring system

    Wider context from the report

    “1. There does not seem to be a robust system in place in the prison healthcare setting for contemporaneous or accurate retrospective documentation of the timing of clinical interactions. I heard evidence and received a further statement, following the conclusion of the inquest, which set out the difficulties that the prison environment causes, in terms of being able to document accurately. However, I remain concerned that the lack of accurate documentation means that subsequent review of the appropriateness of clinical care, in particular, response times is hampered; 2. The interval to further observations being undertaken were not inline with the NEWS2 scoring system and, in oral evidence, it was set out that prisoners were expected to self-report deterioration. This differs from latter information, provided after the conclusion of the inquest. However, it remains a concern. The use of the NEWS2 scoring system remains unclear; the post-inquest information seemingly sets out both that this system was only to used after a positive COVID-19 result but also at daily handover. Whilst recognising that the prison environment differs from a hospital setting, I remain concerned that the care provided was not as guided by the NEWS2 scoring system and that no alternative system appears to be in place that can be used effectively in the prison healthcare setting. ”

    Source location

    Mr Khairul Rahman · 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

    Use NEWS2 to support identification of deteriorating patients and clinical decision-making.

    Verbatim wording from the response

    “Practice Plus Group currently adopts the NEWS2 tool to support identification of the deteriorating patient, in order to aid clinical decision making.”

    Source location

    2021-0226-Response-from-Practice-Plus-Group_Published
    Page 3 · response
    Published 9 July 2021

    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 a service-improvement programme at HMP Pentonville to embed appropriate NEWS2 use, including deteriorating-patient training and distribution of quick-reference cards.

    Verbatim wording from the response

    “Practice Plus Group recognises the importance of NEWS2 scoring to identify potential clinical deterioration and have begun a service improvement project to encourage the appropriate use of the tool and embedding this into practice. A ‘Back to Basics’ workshop has been designed to ‘Identify the Deteriorating Patient’ and ensure escalation of clinical abnormalities. This will be delivered for the healthcare team at HMP Pentonville by 30th November 2021. Within the delivery of the training, small laminated NEWS2 cards will be distributed as an immediate ‘go to guide’ to help support implementing the use of the NEWS2 within clinical assessment and identifying the deteriorating patient.”

    Source location

    2021-0226-Response-from-Practice-Plus-Group_Published
    Page 4 · response
    Published 9 July 2021

    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 communicate guidance for monitoring patients who test positive for COVID-19 in custodial settings.

    Verbatim wording from the response

    “It is important to note that at the time of Mr Rahman’s death there was no clinical guidance produced by NHS England to guide staff around the Management of COVID positive patients in a prison setting. In November 2020, Practice Plus Group developed the ‘Monitoring of patients who test positive for COVID’ Policy and this was updated and communicated to all staff by email”

    Source location

    2021-0226-Response-from-Practice-Plus-Group_Published
    Page 3 · response
    Published 9 July 2021

    Open published response

  2. Gwent

    AI-generated summary

    Thomas Byron Black · 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

    Thomas Byron Black collapsed and reported feeling unwell while in HMP Usk, but prison officers did not seek medical advice over the weekend. He later deteriorated after collapsing again on 23 February 2015 and was pronounced dead in hospital; the stated medical cause was pulmonary thrombo-embolus associated with deep vein thrombosis and Factor V Leiden mutation.

    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 seek medical advice when a prisoner is apparently unwell

    Wider context from the report

    “Prison staff did not seek medical advice when it was apparent that Mr. Black was unwell. ”

    Source location

    Thomas Byron Black · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Worcestershire

    AI-generated summary

    James Paul COLTON · 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

    James Paul COLTON was a serving prisoner who became critically unwell on 29 August 2013 after a period of deteriorating health and died two days later in hospital. Concerns included failure to revisit his diagnosis or escalate treatment, inadequate analgesia, poor continuity and communication of care, and an extremely heavy workload affecting healthcare provision.

    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 reassess diagnoses and escalate treatment despite continuing clinical decline

    Wider context from the report

    “(1) The doctors and nurses at the prison failed to properly diagnose, treat and care for Mr Colton in that they assumed that the diagnosis of mechanical back pain was accurate and took no steps to revisit the diagnosis or to escalate his treatment despite his obvious continuing decline. The failure to consider alternate diagnosis led to him missing his developing cancer and which may, therefore, have contributed to his early death. ”

    Source location

    James Paul COLTON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Hold staff study sessions to discuss case learning and encourage curiosity in clinical situations.

    Verbatim wording from the response

    “Importantly, a couple of study sessions were held in which staff were taken through the case notes of Mr Colton and had an opportunity to discuss learning identified and how they may act in future situations. Whilst there are a number of learning objectives for the day, principally, staff were asked to be open and to be curious in clinical situations. I understand from my Deputy Head of Healthcare at HMP Long Lartin that staff still talk about the learning generated from this case and in the last week there has been an example of staff raising an issue and being encouraged to consider alternative options.”

    Source location

    2015-0021-Response-by-Worcestershire-Health-Care-NHS
    Page 1 · response
    Published 21 January 2015

    Open published response

  4. Portsmouth and South East Hampshire

    AI-generated summary

    GARRY GILBEY · 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

    Garry Gilbey developed worsening arm, chest and breathing symptoms while imprisoned and was later diagnosed with inoperable lung cancer after being admitted to hospital on 25 June 2012. He died on 3 July 2012. The substantive concerns included unclear ambulance-call procedures and emergency thresholds for prison officers, inadequate communication of healthcare events to night staff, and failures to ensure that specialist investigations were arranged, completed and properly checked.

    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

    Unclear and high threshold for recognising a medical emergency

    Wider context from the report

    “1. The Prison did not have a set policy about when an ambulance should be called. This was left to the judgement of the prison officer(s) making an assessment of the prisoner from outside the cell and whether what they observed amounted to a medical emergency. In addition, it was not clear what amounted to a medical emergency and that the threshold was high. This raises genuine concern in relation to those prisoners who do not have 24/7 medically trained staff available to make emergency assessments of prisoners during the night. ”

    Source location

    GARRY GILBEY · 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

    Inadequate training and clarity for night-time staff assessing medical emergencies

    Wider context from the report

    “2. In turn this raises concern about the adequacy of training and clarity of what amounts to a medical emergency for those night time prison staff involved in having to make dynamic risk assessment especially for those prisoners who are at higher risk of a chronic condition developing into an acute episode e.g. during the referral period to a hospital especially when a very serious underlying condition is suspected such as lung cancer that has the capacity to affect breathing suddenly even though a prisoner may initially appear to be able to speak. ”

    Source location

    GARRY GILBEY · 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

    Issue national guidance requiring ambulance calls and immediate ambulance access protocols for prisoners in life-threatening emergencies.

    Verbatim wording from the response

    “Healthcare contracts for prisons are performance managed by NHS England’s Area Teams at a local level, who have not alerted DH Offender Health or the NHS England Health and Justice central team to any particular problems. Guidance was issued by DH and NOMS in 2011 (“Emergency access to establishments for ambulance services”) to all prisons in England, NHS commissioners and NHS ambulance trusts. This sets out when an ambulance should be called to take a prisoner to hospital in life-threatening circumstances. The guidance covers day and night emergencies and makes the following main points:”

    Source location

    2014-0533-Response-by-Department-of-Health
    Page 1 · response
    Published 10 December 2014

    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 emergency-response instructions specifying medical emergency codes, required information, local protocols and staff responsibilities.

    Verbatim wording from the response

    “Calling ambulances Since Mr Gilbey’s death Prison Service Instruction 2013/03 Emergency Response Codes has been issued. The PSI reminds staff who can call a medical emergency, and provides guidance on the use of the correct medical emergency codes, and what information should be communicated to the control room from the scene of the incident. It also states that all Governors must have a Medical Emergency Response Code protocol in place that is based on the PSI and that all prison staff must be made aware of and understand the instruction and their responsibilities during medical emergencies. I have attached a copy of the PSI for your information.”

    Source location

    2014-0533-Response-by-NOMS
    Page 1 · response
    Published 10 December 2014

    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 emergency-access guidance applies during emergencies outside normal healthcare-centre hours, so 24-hour medical cover is not necessarily required.

    Verbatim wording from the response

    “Healthcare contracts for prisons are performance managed by NHS England’s Area Teams at a local level, who have not alerted DH Offender Health or the NHS England Health and Justice central team to any particular problems. Guidance was issued by DH and NOMS in 2011 (“Emergency access to establishments for ambulance services”) to all prisons in England, NHS commissioners and NHS ambulance trusts. This sets out when an ambulance should be called to take a prisoner to hospital in life-threatening circumstances. The guidance covers day and night emergencies and makes the following main points:”

    Source location

    2014-0533-Response-by-Department-of-Health
    Page 1 · response
    Published 10 December 2014

    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

    Continuous in-house healthcare is not provided at every establishment because limited resources make it inefficient and generally unnecessary.

    Verbatim wording from the response

    “All establishments have access to the same level of service that they would receive in the community which is an in-house healthcare service and access to Out of Hours urgent care to an equivalence of the community. As such 24/7 healthcare would not always be provided in-house as this would not be an efficient use of limited resources. Some establishments where there is an in-patient unit will have 24/7 in house healthcare although for the majority of establishments this is not a requirement.”

    Source location

    2014-0533-Response-by-NOMS
    Page 2 · response
    Published 10 December 2014

    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 Ministry of Justice and National Offender Management Service can address training for non-medical prison staff.

    Verbatim wording from the response

    “You were also concerned about the adequacy of training for night time prison staff and the handover of medical information between day/night staff. I am aware that you have also sent a copy of your report to the Ministry of Justice, which oversees the National Offender Management Service (NOMS), which will be able to address prison-related issues such as training for non-medical prison staff.”

    Source location

    2014-0533-Response-by-Department-of-Health
    Page 1 · response
    Published 10 December 2014

    Open published response
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Data last updated 7 September 2026