Recurring concern

Insufficient availability of prison healthcare services outside limited operating hours

Pin Get email alerts Request correction

First reported 22 Oct 2021•Latest report 30 May 2025

Definition

What this concern includes

Includes absent overnight healthcare staff and prison healthcare services whose restricted operating hours leave clinically unsafe gaps in access.

Not included

  • General prison-healthcare policy or specification concerns without an access gap
  • Condition-specific prison treatment failures
  • Community or hospital out-of-hours healthcare
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2021–2025

First to latest report issue date

Stated actions
4

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
NHS England2
Coldingley Prison1
Oxleas NHS Foundation Trust1
Parole Board1
Rochester Prison1
Wealstun Prison1

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. Dorset

    AI-generated summary

    Colin David Lovett · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unavailability of prison healthcare outside limited operating hours

    Wider context from the report

    “(2) The healthcare department at HMP The Verne is only operated between 7.30am and 6pm daily and is not therefore available 24 hours a day. Outside of these operational times, access to healthcare would be via 111 or 999 which could cause delay in action being taken to resolve a hypo glycaemic or hyper glycaemic attack. This will be the position in other prisons nationally. (3) Whilst insulin dependent diabetics are likely to be experts in their own care, some prisoners may have poorly managed diabetes and require support which could be at any time. ”

    Source location

    Colin David Lovett · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work with partners to reduce health inequalities and improve timely, effective healthcare access for people in prison.

    Verbatim wording from the response

    “As signatories to the National Partnership Agreement for Health and Social Care for England, the Department of Health and Social Care and NHS England are committed to working with partners to reduce health inequalities for people in prison and improving services to ensure that people have access to timely and effective healthcare whilst in prison. I would like to inform you that the Chief Medical Officer for England’s report on health in prisons is due to be published this year and will provide recommendations for further action.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 10 June 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    NHS England is responsible for commissioning prison healthcare services and will address healthcare provider operating hours.

    Verbatim wording from the response

    “Following evidence heard at the inquest, you have raised concerns regarding diabetes awareness training among prison staff and emphasised the importance of this in the light of the restricted operating hours of the healthcare provider at HMP The Verne. My response will address the point about staff awareness training, and I understand that NHS England will send a separate response addressing the issue of healthcare operating hours, as they have responsibility for the commissioning of healthcare services within prisons.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 10 June 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Healthcare provision at this Category C prison is required within core hours, considered equivalent to community provision.

    Verbatim wording from the response

    “I understand your concerns about the healthcare services at HMP The Verne not being available 24 hours a day, which could mean delays in action being taken to resolve a hypo glycaemic or hyper glycaemic attack outside of its operational hours. However, this is a Category C prison, and under the Health and Social Care Act 2022, NHS England is required to ensure the provision of healthcare to Category C prisons is within core hours. This is equivalent with community provision.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 10 June 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Integrated care boards are responsible for urgent and out-of-hours healthcare for prisoners.

    Verbatim wording from the response

    “The core hours of healthcare provision are agreed between health and justice commissioners based on local population needs, identified through a comprehensive health needs assessment. The Act states that urgent and out of hours care is the responsibility of integrated care boards for all prisoners. Healthcare providers, supported by NHS England regional health and justice commissioning teams should work with local out of hours and urgent care services to agree effective pathways for any urgent care needs outside of routine healthcare hours.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 10 June 2025

    Open published response
  2. Surrey

    AI-generated summary

    Haydar Jefferies · 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

    Haydar Jefferies was detained at HMP Coldingley and developed severe depression and psychosis before self-ligaturing in his cell on 1 March 2023; he was resuscitated but died at hospital on 5 March 2023 from hypoxic brain injury and pneumonia. The principal concerns included failures to record and share risk-relevant information, refer him promptly to mental health services, provide an adequate mental health assessment and obtain appropriate clinical care and supervision during his acute deterioration.

    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

    Unavailability of clinical mental health provision outside weekday office hours

    Wider context from the report

    “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result: a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions. b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning. ”

    Source location

    Haydar Jefferies · Prevention of Future Deaths report
    Page 5 · 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

    Implement re-commissioned prison healthcare services, including seven-day mental health provision, on-site attendance and out-of-hours urgent referral protocols.

    Verbatim wording from the response

    “I would also like to inform you that since Haydar’s tragic death, the healthcare at HMP Coldingley, including mental health services, has been re-commissioned.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 27 December 2024

    Open published response
  3. Mid Kent and Medway

    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

    Unavailability of in-house healthcare during the night for prisoners suspected to be under the influence

    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

    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 position was interpreted

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

    PFD Monitor interpretation

    NHS England is responsible for explaining whether 24-hour healthcare should be commissioned in Category C prisons because of drug-related patient safety risks.

    Verbatim wording from the response

    “such as psychoactive substances ‘spice’ are explored. Change, Grow, Live (CGL) are subcontracted by Oxleas to provide psychosocial substance misuse and they have a large caseload at HMP Rochester who undertake group and 1:1 work to address substance misuse issues including the use of psychoactive substances, and encourage harm minimisation and ultimately recovery. Healthcare attend to those suspected to be under the influence of substances during the day until 21:00 as contracted by NHS England. As a Category C prison, Rochester, in accordance with most Category C prisons does not have 24-hour healthcare provision. The contracts for Category C prisons do not normally make provision for healthcare services at night if there is no Inpatient department, and therefore no prisoners requiring 24-hour healthcare provision.”

    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

    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
  4. West Yorkshire Eastern

    AI-generated summary

    Lewis Steven Johnson · Prevention of Future Deaths report

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

    Report summary

    Lewis Steven Johnson was found unresponsive with a neck ligature at HMP Wealstun on 12 December 2019 and later died in hospital following a further cardiac arrest. The report raised concerns about the absence of overnight healthcare staff and the prison officers’ delayed and inadequate response, including lack of CPR, defibrillator use and consideration of the recovery position.

    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 overnight healthcare staff in the prison

    Wider context from the report

    “(1) HMP Wealstun does not have nurses or other healthcare staff in the prison during the night. ”

    Source location

    Lewis Steven Johnson · 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

    Review local first-aid staffing risks, including night provision, and continue regular reviews to maintain coverage.

    Verbatim wording from the response

    “At HMP Wealstun the local risk assessment was last reviewed in October 2022. Consideration was given to the risk profile across all areas of the prison, paying particular attention to the night provision, due to there being no healthcare staff available during that time to provide emergency assistance should the need arise. Regular reviews will continue to be conducted to ensure that the needs of the prison continue to be met.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 19 December 2022

    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 first-aid training requirements and local risk assessments are considered sufficient to ensure enough trained staff are deployed at all times.

    Verbatim wording from the response

    “It may be helpful for me to clarify the requirements currently in place for all establishments around the provision of first aid trained staff. Whilst there is currently no requirement for all prison staff to be trained in first aid, all prison officers receive emergency first-aid at work (EFAW) training, including how to administer CPR, during their entry level training, for use in their duties. Governors are required to ensure that there are sufficient numbers of trained staff on duty at all times. They do this by producing a detailed local first aid risk assessment to determine the number of first aid at work (FAW) and EFAW trained staff needed at the establishment, and by ensuring that they are deployed appropriately.”

    Source location

    Response from HM Prison & Probation Service
    Page 1 · response
    Published 19 December 2022

    Open published response
  5. Dorset

    AI-generated summary

    Anthony John Larcher · Prevention of Future Deaths report

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

    Report summary

    On 21 March 2018, Anthony John Larcher, a serving prisoner at HMP Guys Marsh, was found in his cell. The report identifies concerns about monitoring prisoners under the influence of psychoactive substances, the lack of round-the-clock healthcare, healthcare involvement in ACCT reviews, the accessibility of medical information, and the reception of prisoners arriving in large cohorts.

    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 24-hour healthcare across the prison estate

    Wider context from the report

    “ii. I have concerns that future deaths could occur due to the lack of 24 hour healthcare across the prison estate. I would therefore request consideration be given to the provision of healthcare to all prisons 24 hours a day, 7 days a week. ”

    Source location

    Anthony John Larcher · Prevention of Future Deaths report
    Page 5 · 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

    Existing needs-based commissioning and round-the-clock external, emergency, general-practitioner and first-responder access are considered sufficient without universal onsite 24/7 healthcare.

    Verbatim wording from the response

    “All prisons have a health needs assessment (HNA) carried out prior to services being commissioned. This ensures the correct level of healthcare is delivered for the population need.”

    Source location

    2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
    Page 2 · response
    Published 22 October 2021

    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 matters in the prison estate are commissioned by NHS England and Improvement, which has already provided a response.

    Verbatim wording from the response

    “NHS England and NHS Improvement (NHSEI) is responsible for the commissioning of healthcare for the prison estate. I am aware that NHSEI has provided a response to you on the matters of concern in your report relating to healthcare. I will not repeat the detail of that response. However, I offer the following comments.”

    Source location

    2021-0356-Response-from-Department-of-Health-Social-Care_Published
    Page 1 · response
    Published 22 October 2021

    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

    Matters of concern i, ii, iii and v do not relate to NHS Digital, so it has no comment on them.

    Verbatim wording from the response

    “We do not consider that matters of concern i, ii, iii or v relate to NHS Digital and thus have no comment on these.”

    Source location

    2021-0356-Response-from-NHS-Digital_Published
    Page 1 · response
    Published 22 October 2021

    Open published response
Back to top

Data last updated 7 September 2026