Recurring concern

Unreliable handling of external clinical correspondence in prisons

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First reported 14 Nov 2013•Latest report 4 Dec 2019

Definition

What this concern includes

Includes prison processes for receiving, recording, routing, acknowledging, investigating and responding to external clinical correspondence concerning a prisoner's health, welfare or treatment, including correspondence from treating clinicians and hospitals.

Not included

  • Excludes general prison correspondence failures with no clinical, health or treatment relevance.
  • Excludes failures involving family or friends' concerns where no external clinical correspondence or clinician-originated information is involved.
  • Excludes failures to provide or review clinical information after it has been reliably received and routed, unless the correspondence-handling process itself is deficient.
  • Excludes generic clinical-record, communication or staffing deficiencies that are not directly tied to handling external clinical correspondence in prison.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2013–2019

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1
Forest Bank Prison1
Hewell 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. Worcestershire

    AI-generated summary

    Gareth Wycliffe WARBURTON · 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

    Gareth Wycliffe Warburton had undergone a double lung transplant and was taking anti-rejection medication when he arrived at HMP Hewell. A prescription error resulted in him receiving half his usual dose, and he died after chronic rejection of his transplanted lungs. The report raised concerns about prescription systems, staffing and the handling of important health-related correspondence 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

    Failure to pass important prisoner health and welfare letters to the prison healthcare team

    Wider context from the report

    “(1) Letters dated 16.10.17 and 27.11.17 from ████████ Mr. Warburton's treating clinician at the Queen Elizabeth Hospital, Birmingham to then Governor of HMP Hewell Gareth Sands, highlighting concern about the prescription error, asking for more information about the error, and seeking assurances that Mr. Warburton would continue to receive all required medication, were neither acknowledged nor answered by the Governor; (2) Furthermore, although such letters ought to have been passed on to the prison healthcare team, the evidence suggested that this was not done. Investigations carried out by current Governor Anthony Morrow failed to establish what had happened to these letters; (3) As to the suggestion that perhaps these letters were never received by the prison, it was apparent that the same letters had been sent to, and received by, members of Mr. Warburton's family; (4) Accordingly, I am satisfied that it is probable that these letters did reach the prison, but were not dealt with satisfactorily; (5) I am concerned that, as long as there is a risk that letters which seek or contain important information about a prisoner's health and welfare are not dealt with and go unanswered, there remains a risk to prisoners' lives at HMP Hewell. ”

    Source location

    Gareth Wycliffe WARBURTON · 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

    Failure to acknowledge and answer letters containing important information about prisoners' health and welfare

    Wider context from the report

    “(1) Letters dated 16.10.17 and 27.11.17 from ████████ Mr. Warburton's treating clinician at the Queen Elizabeth Hospital, Birmingham to then Governor of HMP Hewell Gareth Sands, highlighting concern about the prescription error, asking for more information about the error, and seeking assurances that Mr. Warburton would continue to receive all required medication, were neither acknowledged nor answered by the Governor; (2) Furthermore, although such letters ought to have been passed on to the prison healthcare team, the evidence suggested that this was not done. Investigations carried out by current Governor Anthony Morrow failed to establish what had happened to these letters; (3) As to the suggestion that perhaps these letters were never received by the prison, it was apparent that the same letters had been sent to, and received by, members of Mr. Warburton's family; (4) Accordingly, I am satisfied that it is probable that these letters did reach the prison, but were not dealt with satisfactorily; (5) I am concerned that, as long as there is a risk that letters which seek or contain important information about a prisoner's health and welfare are not dealt with and go unanswered, there remains a risk to prisoners' lives at HMP Hewell. ”

    Source location

    Gareth Wycliffe WARBURTON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Manchester West

    AI-generated summary

    Anthony Brian Flynn · 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

    Anthony Brian Flynn, who had diagnosed testicular cancer, was remanded into custody at Forest Bank Prison on 24 July 2012 and died there on 28 September 2012. The report raised concerns that he was handcuffed and chained during hospital appointments and examination, that a consultant’s concerns about the lack of compassion and difficulty conducting a sensitive examination were not acknowledged or investigated, and that training and procedures concerning restraints and clinicians’ powers needed consideration.

    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 acknowledge and investigate clinicians’ concerns about prisoner treatment

    Wider context from the report

    “(3) On the 10th September 2012, ████████ a Consultant Clinical Oncologist at the Royal Preston Hospital who was treating Mr Flynn, wrote to HMP Forest Bank expressing concerns. She said “I was extremely concerned that there was an absolute lack of compassion demonstrated to what was a very sick man who was extremely distressed in the clinic. Unfortunately I felt that there was no really empathy in terms of the huge amount he had already received treatment for the significant side effects he has had and certainly conducting my examination of the abdomen and pelvis including the genitalia in a sensitive manner was extremely difficult.” Evidence given at the Inquest confirmed that Mr Flynn had been chained and handcuffed during the examination to which the Doctor refers. (4) ████████ letter was received at HMP Forest Bank, but it was never acknowledged. No reply was sent, nor were the matters of concern described in the letter, especially that the Doctor had found it ‘extremely difficult’ to conduct the examination of Mr Flynn, ever investigated. (5) Further evidence given at the Inquest revealed that: a) When a prisoner is being escorted to hospital or other appointments escorting officers can, if they consider it appropriate, telephone the prison and seek permission to remove or lengthen the prisoner’s restraints. b) Clinicians have the power to request that the action described in a) be taken, but most clinicians are unaware that they can do this. (6) The evidence concluded that there was a need to consider the following: a) The training of prison officers in relation to escorting prisoners, particularly during hospital visits. b) Procedures for making clinicians, particularly hospital clinicians, aware of their powers in relation to prisoners attending for treatment. ”

    Source location

    Anthony Brian Flynn · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026