Recurring concern

Failure to provide private healthcare conversations for prisoners

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First reported 16 Jun 2023•Latest report 11 Mar 2026

Definition

What this concern includes

Includes failures in prison healthcare or recovery-support interactions to provide a private conversation, including use of an observation hatch or other non-private arrangement when no identified practitioner-safety or operational risk requires it, and conversations conducted with another prisoner or unauthorised person present.

Not included

  • Excludes observation through a hatch or other remote interaction where a documented safety, security or infection-control risk requires separation.
  • Excludes general prison privacy, accommodation or confidentiality concerns that do not concern a healthcare or recovery-support conversation.
  • Excludes failures of clinical assessment, treatment, record review or therapeutic engagement where privacy of the conversation is not the unsafe condition.
  • Excludes ordinary communication with prisoners in which confidential healthcare information or safety-relevant assessment is not involved.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2023–2026

First to latest report issue date

Stated actions
1

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 Service1
Midlands Partnership University NHS Foundation Trust1
Pentonville Prison1
Phoenix Futures1
Practice Plus Group1

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

    Peter Asher CAMPBELL · 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

    Peter Asher Campbell collapsed in his prison cell at Pentonville after smoking a drug and died five days later. The principal concerns were the failure to prevent drugs entering the prison and shortcomings in the prison drug service’s response, including inadequate engagement, harm-minimisation advice, staff training, supervision and auditing.

    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 conduct recovery-worker interactions privately

    Wider context from the report

    “For Phoenix and PPG Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated. The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed. However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation: • She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was. • She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been. • She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have. • She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk. • Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have. • She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death. • The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman). • She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only. Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest. ”

    Source location

    Peter Asher CAMPBELL · Prevention of Future Deaths report
    Page 3 · 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

    Responsibility for Phoenix Futures’ service and employees rests with Phoenix Futures, which is expected to respond separately.

    Verbatim wording from the response

    “Likewise, the points raised under the heading for Phoenix and PPG mainly relate to Phoenix Futures and the steps taken by one of their employees. Whilst we work closely with Phoenix as one of our subcontractors at Pentonville and work together to improve services and continue our strong working partnership, we do not propose to comment on their service or individual employees. We understand that Phoenix will be responding to the points raised separately.”

    Source location

    Response from Practice Plus Group (1)
    Page 3 · response
    Published 17 April 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

    Prison authorities decide whether cell doors open, and Phoenix Futures staff cannot open them because they do not carry cell keys.

    Verbatim wording from the response

    “Phoenix Futures is committed to continuous learning and to developing best practice that safeguards the wellbeing of both people who access services and our colleagues. Whether a cell door is opened is not a decision that Phoenix Futures make, Phoenix Futures are not permitted to carry cell keys. Additionally, within the prison environment it is commonplace for a variety of disciplines; Chaplain, Iman, Education and civilians, to speak to prisoners through their door.”

    Source location

    Response from Phoenix Futures
    Page 2 · response
    Published 17 April 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

    Through-door consultations remain necessary where prison rules or staff risk assessments determine that opening the door would be unsafe.

    Verbatim wording from the response

    “Before offering any guidance or support to a person accessing services, an assessment of risk must be carried out. If that person appears to be under the influence, the prison guidelines dictate that the cell door will not be opened furthermore Recovery Workers are not expected to place themselves in situations that could compromise their safety. We also recognise that many of our colleagues are female, and this must be factored into any assessment of risk.”

    Source location

    Response from Phoenix Futures
    Page 2 · response
    Published 17 April 2026

    Open published response

  2. Manchester North

    AI-generated summary

    Vaughan Lee WHALLEY · 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

    Vaughan Lee WHALLEY was found unresponsive after being released on bail from police custody and died in hospital on 21 February 2023 despite surgery and supportive care. The principal concerns were that no assessment of his risk of suicide or self-harm on release took place, communication to police about any assessment was unclear, and the practitioner’s contact and subsequent review did not meet best practice or identify learning adequately.

    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 conduct the conversation in the same room where no practitioner risk was posed

    Wider context from the report

    “(3) The conversation between the Practitioner and the Deceased took place through an observation hatch in circumstances where no risk was posed to the Practitioner from being in the same room as the Deceased. This was not best practice. ”

    Source location

    Vaughan Lee WHALLEY · 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

    Revise the Working in Police Custody procedure to govern observation-hatch assessments and recording of assessment location, participants, rationale, and declined needs assessments.

    Verbatim wording from the response

    “Following a review, the Health and Justice Services SOP ‘Working in Police Custody’ has been revised to include guidance for staff on the circumstances under which it is appropriate to review somebody through an observation hatch and the process for recording where and with whom an assessment took place and the rationale for conducting an assessment through an observation hatch if this was necessary. The SOP will be ratified at the MPFT Policy and Procedures Committee on the 09/08/23. I will forward a copy of the SOP as soon as it has been ratified.”

    Source location

    Response from Midlands Partnership University NHS Foundation Trust
    Page 3 · response
    Published 18 October 2023

    Open published response
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Data last updated 7 September 2026