Recurring concern

Unsafe operation of prison segregation procedures

First to latest report 20 Dec 2013 — 27 Jan 2023

Reports that mention this concern
7
Times this concern has been raised
9
Stated actions linked to this concern
5

What this concern includes

Includes failures of the named prison segregation process, including decisions to impose or continue segregation, required healthcare fitness assessments, authorisation, documentary decision tools, medical checks, observation, review and safeguards for prisoners held in segregation.

What is not included
  • Excludes generic prison staffing, training, communication or documentation deficiencies unless they directly impair the prison segregation process.
  • Excludes custody observation, healthcare assessment or prisoner welfare concerns outside segregation unless the report explicitly connects them to a segregation decision or safeguard.
  • Excludes general cell conditions, security arrangements or self-harm hazards where no failure of the segregation process is identified.
  • Excludes unlawful or unsafe segregation outcomes where the report does not identify a deficient segregation procedure or control.

Reports and published responses 7 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Worcestershire

    AI-generated summary

    Andrew Paul SHIRLEY · 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

    Andrew Paul Shirley, a 25-year-old prisoner at HMP Hewell, was found unresponsive in his cell on 23 March 2021, suspended by a ligature, and was pronounced dead at the scene. The inquest found that healthcare and mental healthcare staff failed to sufficiently identify, manage, and share information about his risk of suicide and self-harm, and that these failures probably caused or contributed to his death. Concerns were also raised about staff training on suicide and self-harm risk and the Initial Segregation Health Screen process.

    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 training for Duty Governors in completing the Initial Segregation Health Screen algorithm document

    Wider context from the report

    “(2) I also heard evidence that, despite the introduction of a new Initial Segregation Health Screen algorithm document for prisoners in the Segregation Unit, Duty Governors at the prison had not yet received any training about the steps they should take in order to complete that document appropriately. ”

    Source location

    Andrew Paul SHIRLEY · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver training to all Duty Governors on segregation risk, policy requirements and the Initial Segregation Health Screen process.

    Verbatim wording from the response

    “HMP Hewell has developed Duty Governor guidance for managing the risk of segregation and delivered a training session to all Duty Governors in March 2023. The training included information on the policy requirements, how to review periods of increased risk and the process of the Initial Segregation Health Screen.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 27 February 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 comprehensive training on completing Initial Segregation Health Screens, including clinical assessment, accountability, testing and scenario-based learning.

    Verbatim wording from the response

    “Practice Plus Group has taken immediate action to address this concern and our Director of Nursing & Quality has developed a comprehensive training session. The training incorporates an overview of the prison processes for segregation, clinical assessment (utilising ISHS and other available information to support decision making) and professional accountability. The session includes a knowledge-based test and scenario-based learning. The training session and associated resources are enclosed to support this response.”

    Source location

    Response from Practice Plus Group
    Page 3 · response
    Published 27 February 2023

    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

    PPG is responsible for segregation health screening and provides the related algorithm training to MPFT staff.

    Verbatim wording from the response

    “Health Screen Algorithm training is provided to MPFT staff by PPG. This is now in place and all registered nurses at HMP Hewell, inclusive of agency nurses, had completed the training by 3 February 2023. A new member of staff who started 2 weeks ago is the only member of staff not to have completed this but will do so as part of their induction. This is part of the required training for staff working in prisons and is provided as part of and will be monitored within our Induction process. We are in dialogue with PPG about how we can get our staff trained to also deliver this training.”

    Source location

    Response from Midlands Partnership NHS Foundation Trust
    Page 5 · response
    Published 27 February 2023

    Open published response

  2. Lancashire and Blackburn with Darwen

    AI-generated summary

    Andrew Patrick Jones · 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

    Andrew Patrick Jones, a 37-year-old male prisoner, died after being transferred from a vulnerable-prisoner wing, unlawfully segregated and deprived of healthcare assessment, basic amenities and prescribed medication. The report identified concerns about inadequate risk assessment and communication, the absence of effective personal-officer support and transfer protocols, inconsistent medication systems, unlawful segregation, and failures relating to adjudication and monitoring. The expert psychiatric evidence stated that these factors created the “perfect storm”, and the jury concluded that the prison regime contributed to the death and added a rider of Neglect.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to detect unlawful segregation and deprivation of basic amenities

    Wider context from the report

    “However, the message from the prison governor undertaking the adjudications that the adjudication would not occur that day and would be delayed to the following day did not reach the wing and was not conveyed to Andrew Jones. This is a breach of prison rules, did not detect that Andrew Jones was unlawfully segregated, failed to covey information to him and also failed to detect he did not even have the benefit of basic amenities such as a shower, a telephone call and fresh air. ”

    Source location

    Andrew Patrick Jones · Prevention of Future Deaths report
    Page 6 · 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

    Routine continuation of cell-door segregation without required safeguards

    Wider context from the report

    “Unlawful use of segregation was routine practice since the introduction of the new rules some 3-4 years earlier. At this is a substantial understatement of what was taking place at HMP Garth. Since the time of introduction, on a jail wide basis, prisoners were routinely segregated behind their cell doors for periods after the initial four hours had expired without any of the safety features of segregation including assessment by healthcare to determine if segregation would adversely affect the health of the prisoner, authorisation by a Governor, regular checks et cetera. ”

    Source location

    Andrew Patrick Jones · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  3. Preston and West Lancashire

    AI-generated summary

    Marcin Miroslaw Mazarek · 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

    Marcin Miroslaw Mazarek became mentally unwell, a condition exacerbated by a very long period in segregation, began to self-harm and ultimately hanged himself. Concerns included very poor medical record keeping, missed or unrecorded medical checks in segregation, an inappropriately long period in segregation, failure to properly implement ACCT procedures, lack of multidisciplinary working and mental health involvement, and inadequate reporting by discipline and medical teams.

    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 carry out required medical checks in segregation

    Wider context from the report

    “(1) Medical record keeping was of very poor quality (2) The daily medical checks in segregation by members of the nursing team and the tri-weekly checks by the GP team, were frequently not recorded in the medical notes and / or did not take place. ”

    Source location

    Marcin Miroslaw Mazarek · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Inner South London

    AI-generated summary

    Richard Walsh · 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

    Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.

    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

    Inadequate nurse assessment of fitness for segregation

    Wider context from the report

    “3. That the inadequacy of the nurse assessment of fitness for segregation in HMP Highdown (see m) above) is a risk. ████████ was not ACCT trained and it appeared that he was unaware of PSI 1700. The inadequacy may reflect individual or wider weaknesses in assessment or choice of assessors that mean that prisoners go to segregation when they should be in the health care wing, or that they go without observation, when they should be on an ACCT and receive extra support. ”

    Source location

    Richard Walsh · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide scenario-based induction training on completing Fitness for Segregation forms, with trainee declaration and manager competency confirmation.

    Verbatim wording from the response

    “Since the induction pack was introduced “Seg Algorithms” or alternatively “Fitness for Segregation” forms are also part of the Virgin Care Induction pack for healthcare colleagues at HMP High Down. During induction these are scrutinised between staff and their line manager. At the conclusion of the training, the member of staff will sign, and thereby declare, that they have received relevant training before their induction is completed and they are able to work independently. As part of the training, Virgin Care healthcare colleagues undergo scenario-based training to allow them to practice completing and signing “Fitness for Segregation” forms. An example of the form is attached at Appendix B.”

    Source location

    2016-0377-Response-by-Virgin-Care-Limited
    Page 2 · response
    Published 26 February 2017

    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

    Conduct four annual audits of Fitness for Segregation documentation and related clinical, history-sheet and ACCT records, addressing material errors through supervision or training.

    Verbatim wording from the response

    “Although we are confident that in this case the Fitness for Segregation form was completed correctly, we have also implemented an auditing process to further assure ourselves of this (see Appendix D). Our Lead Nurses within the prison will now carry out four audits throughout each year ensuring that these forms have been filled out accurately, that an appropriate entry is made on the clinical system (SystmOne), an appropriate entry is made on the prisoner’s history sheet and, where appropriate, an entry on the ACCT document is also made. Any material errors should therefore be picked up and, where appropriate, will be addressed at management supervision sessions, with additional training to ensure their competency.”

    Source location

    2016-0377-Response-by-Virgin-Care-Limited
    Page 3 · response
    Published 26 February 2017

    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 Fitness for Segregation form was completed correctly, and the available information supported the assessment that the patient was fit for segregation.

    Verbatim wording from the response

    “The Coroner considered at the Inquest that the Fitness for Segregation form was not completed accurately by ████████ in the case of Richard Walsh. However, having reviewed the documentation as part of our response to the inquest, we consider that ████████ had completed this form correctly and the information he had at his disposal meant that this gentleman was fit for segregation. The patient was further reviewed by another nurse who also deemed him fit for segregation. ████████ appears to have been led to doubt himself at the inquest.”

    Source location

    2016-0377-Response-by-Virgin-Care-Limited
    Page 2 · response
    Published 26 February 2017

    Open published response

  5. Nottinghamshire

    AI-generated summary

    Shalan Blackwood · 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

    Shalan Blackwood died at HMP Nottingham on 5 August 2015 as a result of bleeding from a duodenal ulcer. The report identified concerns about inadequate care and supervision for prisoners with complex physical or mental health needs, insufficient staffing for prisoners in segregation requiring a four-person unlock, unclear decision-making tools, widespread use of New Psychoactive Substances, and insufficient recognition of urgent physical symptoms obscured by mental health issues.

    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 or unavailable documentary tool for decisions about prisoners remaining in Segregation

    Wider context from the report

    “4. That the documentary tool for decision making between prison staff and healthcare staff, as to whether a prisoner is fit to remain in Segregation and should do so, is unclear in or in use. ”

    Source location

    Shalan Blackwood · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Worcestershire

    AI-generated summary

    Severyn Witold Glowinski · 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

    Severyn Witold Glowinski, a serving prisoner diagnosed with paranoid schizophrenia, was transferred to segregation and remained there for a little under a fortnight. He was found hanging in his cell on the evening of 3 July 2013 while subject to an open ACCT for self-harm. Concerns included poor communication about his care plan, inaccurate paperwork copied from another prisoner’s file, and a lack of awareness of requirements concerning the segregation of prisoners on an open ACCT.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure accurate documentation for review and authorisation of further segregation detention

    Wider context from the report

    “(2) The documents to review and authorise his further detention in the Segregation Unit were completed by the way of "cutting and pasting" from other prisoner's files. It was clear that the information on Mr Glowinski's paperwork was incorrect and had been transposed from another prisoner. ”

    Source location

    Severyn Witold Glowinski · Prevention of Future Deaths report
    Page 1 · 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

    Delays in commencing risk assessments for proposed relocation from segregation

    Wider context from the report

    “(1) There appeared to be no communication between the Residential Wing and the Segregation Unit as to the plan for Mr Glowinski. It appeared that the Segregation staff were unaware that the wing staff wanted to have him risk assessed for a move to another location and in fact the risk assessment was not commenced until the day before his death. ”

    Source location

    Severyn Witold Glowinski · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Inner South London

    AI-generated summary

    Adrian 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

    Adrian Johnson died by an act of accidental hanging between 12.50 and 13.55 on 13 May 2010 in the Segregation Unit of HMP Belmarsh. The report identified failures in initial screening and ACCT review processes, including inadequate attention to mental health assessment, medication needs, nicotine dependency, clinical information and protection measures. Concerns remained about prison screening for tobacco withdrawal and the consistency and adequacy of ACCT case management and observation decisions for vulnerable prisoners.

    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 ensure fully informed decisions on reducing observations for vulnerable prisoners in the Segregation Unit

    Wider context from the report

    “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be. (2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners ”

    Source location

    Adrian Johnson · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver ACCT case-manager refresher training reinforcing multidisciplinary reviews, relocation handovers, risk-information sharing, and exceptional use of segregation.

    Verbatim wording from the response

    “National policy contained within PSI 64/2011 “Management of prisoners at risk of harm to self, to others and from others (Safer Custody)” reminds staff of the mandatory requirement that ACCT case reviews “Be multi-disciplinary where possible”. Colleagues at HMP Belmarsh have confirmed that the Governor and all managers (including custodial managers and supervising officers) will attend further ACCT Case Manager refresher training, in part to underline the importance of a multidisciplinary attendance at case reviews, and the need to seek contributions from relevant departments, including healthcare staff and mental health”

    Source location

    2013-0364-Response-by-NOMS
    Page 2 · response
    Published 20 December 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026