9 Feb 2026 Gareth Chumber-Kelly · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to retain documentation accompanying prisoners during reception View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Gareth Chumber-Kelly · 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 Chumber-Kelly died after hanging himself while in custody at HMP Pentonville on 17 July 2023. The report identified concerns about lost or incomplete transfer documentation, inadequate recognition and management of suicide and self-harm risks, insufficient staff training, failures to provide basic life support, and inadequate staffing and support during crucial periods.
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 retain documentation accompanying prisoners during reception
Wider context from the report “(1) The court heard evidence from prison staff that the reception process at HMP Pentonville was inefficient and slow and that paperwork would be sometimes be lost . This creates a risk to the safety and well-being of prisoners as the documentation accompanying the prisoner as they are conveyed to prison may contain (as was the case with Mr Chumber-Kelly) very important information about the prisoners which is relevant to ensuring all appropriate steps and measures are put in place to protect them. The Governor at HMP Pentonville told the court that no steps have been taken to address this recurrent problem, and the risk of important documentation being lost , and there has been no dialogue with Serco to address this issue.
” Source location Gareth Chumber-Kelly · Prevention of Future Deaths report
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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 a digital induction passport to consolidate, store and share key risk information during reception.
Verbatim wording from the response “HMP Pentonville has introduced a digital induction passport to consolidate key risk information from paper records into a secure electronic format. This enables relevant information to be accurately captured, stored, and shared between departments, reducing the likelihood of omissions or data loss during the induction process.” Source location Response from HMPPS
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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 reception procedures and implement necessary improvements identified through the review.
Verbatim wording from the response “To strengthen oversight of early days in custody, the prison has appointed a Head of Early Days with specific responsibility for the reception function. As part of their remit, they are leading a comprehensive review of reception procedures to identify any aspects, such as documentation handling, that may require improvement and to implement any necessary changes.” Source location Response from HMPPS
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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 digital Person Escort Records for PECS movements and enable authorised professionals to update them before arrival.
Verbatim wording from the response “Following the implementation of the Book a Secure Move (BaSM) system, the PECS Contract Management Team has ensured that digital Person Escort Records (DPERs) are available for all prisoners moved by PECS suppliers between courts, prisons and police stations. Recent system enhancements enable authorised professionals, including medical practitioners and L&D services, to update a prisoner’s DPER directly following assessment. These updates are visible to receiving establishments once the prisoner is booked in from court or prison, prior to arrival.” Source location Response from HMPPS
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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 Qualified medical professionals and Liaison and Diversion services are responsible for creating, maintaining and transferring healthcare and associated risk information.
Verbatim wording from the response “The Prison Escort and Custody Services (PECS) team within HMPPS recognises the importance of the timely and accurate transfer of risk and safeguarding information and treats this as a matter of serious operational priority. Responsibility for the creation, maintenance and clinical transfer of healthcare and associated risk information rests with qualified medical professionals. In this case, Liaison and Diversion (L&D) services are responsible for ensuring that relevant records are effectively shared with receiving prison healthcare teams. The PECS contracts do not place responsibility on PECS suppliers for the physical transfer of hard-copy medical or risk documentation between courts and prisons.” Source location Response from HMPPS
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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 PECS suppliers are not contractually responsible for physically transferring hard-copy medical or risk documentation between courts and prisons.
Verbatim wording from the response “The Prison Escort and Custody Services (PECS) team within HMPPS recognises the importance of the timely and accurate transfer of risk and safeguarding information and treats this as a matter of serious operational priority. Responsibility for the creation, maintenance and clinical transfer of healthcare and associated risk information rests with qualified medical professionals. In this case, Liaison and Diversion (L&D) services are responsible for ensuring that relevant records are effectively shared with receiving prison healthcare teams. The PECS contracts do not place responsibility on PECS suppliers for the physical transfer of hard-copy medical or risk documentation between courts and prisons.” Source location Response from HMPPS
Open published response
20 Oct 2025 Declan Carr · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1
Failure to ensure continuity of psycho-social drug misuse support during prisoner transfers View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
NHS England
Use nationally agreed clinical templates, including Court, Release and Transfer Out screening, to standardise information sharing and healthcare delivery.
View source
NHS England
Audit continuity of care for relevant transfers between HMP Hull and HMP Humber.
View source
NHS England
Complete a second audit against the same continuity-of-care parameters in January 2026.
View source
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AI-generated summary
Declan Carr · 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 28 August 2023, Declan Carr was found deceased in his cell at HMP Humber and was declared deceased by paramedics. The report identified failures involving communication about his psychosocial substance-misuse support during transfer between prisons, healthcare reception screening, induction documentation and allocation of a keyworker. It raised concern that inadequate continuity of psychosocial support for drug misuse could pose a risk of future deaths.
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 continuity of psycho-social drug misuse support during prisoner transfers
Wider context from the report “Mr Carr was receiving psycho-social support regarding his substance misuse from healthcare services whilst he was in HMP Hull. He was due to have a further appointment with them on 16th August 2023. However, on this date Mr Carr was transferred to HMP Humber.
HMP Humber were not made aware that Mr Carr was receiving psycho-social support and there was no handover to the support services in HMP Humber. There was then no support in place for Mr Carr.
During the inquest I heard evidence that if Mr Carr had been receiving clinical support for drug misuse there would have been a handover for that to continue.
I was also made aware that HMP Humber and HMP Hull now have a local policy in place to allow the prisons to share information about those that are receiving psycho-social support when transferring prisoners between these 2 prisons as they are the same agency that provide that service.
However, I was informed that this a purely local arrangement and this is not a process that happens nationally and would cease if one of the prisons changed providers.
If there is a lack of continuity of care for prisoners receiving psycho-social for drug misuse support then there is a risk of future deaths occurring.
” Source location Declan Carr · Prevention of Future Deaths report
Open source report
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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 nationally agreed clinical templates, including Court, Release and Transfer Out screening, to standardise information sharing and healthcare delivery.
Verbatim wording from the response “There are nationally agreed clinical templates embedded on SystemOne, which is an electronic patient medical record system. One of these templates is specific to Court, Release and Transfer Out screening. A copy of the template has been attached with this response. The purpose of national agreed templates is to ensure standardised healthcare delivery aligned with National Institute for Health and Care Excellence (NICE) guidance and key performance indicators.” Source location Response from NHS England
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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 Audit continuity of care for relevant transfers between HMP Hull and HMP Humber.
Verbatim wording from the response “For assurance, an audit on the continuity of care between HMP Hull to HMP Humber for those in service with CGL not prescribed opioid substitution therapy was conducted for transfers in June 2025. This audit confirmed that:” Source location Response from NHS England
Open published response
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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 Complete a second audit against the same continuity-of-care parameters in January 2026.
Verbatim wording from the response “A second audit will be completed against the same parameters in January 2026. There was no action plan attached to the audit, as the findings showed that the pathway was being followed correctly and 100% of those transferred from HMP Hull were picked up and a referral opened in HMP Humber.” Source location Response from NHS England
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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 existing transfer pathway was considered sufficient because it was followed correctly and referrals were opened for all transferred service users.
Verbatim wording from the response “A second audit will be completed against the same parameters in January 2026. There was no action plan attached to the audit, as the findings showed that the pathway was being followed correctly and 100% of those transferred from HMP Hull were picked up and a referral opened in HMP Humber.” Source location Response from NHS England
Open published response
7 Feb 2025 Anthony Binfield and 2 others · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Lack of a formal prison-to-prison transfer management system View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Anthony Binfield and 2 others · 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 Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning from previous deaths.
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 a formal prison-to-prison transfer management system
Wider context from the report “I heard evidence that there is no formal policy framework or system for managing the progress of prison-to-prison transfers , including a lack of expected response times or formal escalation plan if a prison fails to provide any response.
” Source location Anthony Binfield and 2 others · Prevention of Future Deaths report
Open source report
7 Oct 2024 John Raymond EYRE · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Lack of national guidance or policy on returning prisoners to custodial settings when prison healthcare concerns have not been considered by the consultant View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
John Raymond EYRE · 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
John Raymond Eyre was a serving prisoner whose health deteriorated in 2022, including recurrent neutropenic sepsis, and he died in hospital on 20 November 2022 from pneumonia, with liver disease also recorded. Concerns included the lack of a concrete escalation route when prison healthcare staff challenged his discharge and the absence of national guidance on returning a prisoner to custody when those concerns had not been considered by the consultant.
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 national guidance or policy on returning prisoners to custodial settings when prison healthcare concerns have not been considered by the consultant
Wider context from the report “(2) There was no national guidance document, or national policy in place, which outlined whether a prisoner should be returned to a custodial setting in the absence of the prison healthcare provider's concerns being considered by the patient's consultant.
” Source location John Raymond EYRE · Prevention of Future Deaths report
Open source report
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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 Ask officials to consider whether hospital discharge guidance should explicitly require consideration of care-provider concerns before discharge to custodial settings.
Verbatim wording from the response “As set out in the Hospital Discharge and Community Support Guidance (January 2024), NHS bodies should work closely with care providers and other partners to ensure people’s care is timely, optimal and co-ordinated, while also practising active risk management to reach a reasonable balance between safety and minimising delays when patients are ready to be discharged. I will ask my officials to consider whether an amendment to the hospital discharge guidance is required to make more explicit the obligation to consider concerns raised by care providers before the discharge of patients to custodial settings. Furthermore, as required and described in the Health and Social Care Act 2012, patients within secure settings should receive the same quality and access of healthcare as the rest of the population, both in terms of the range of interventions to meet their needs, and the quality” Source location Response from DHSC
Open published response
31 May 2024 Frazer Charlie Williams · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 7
Lack of guidance on transferring prisoners under healthcare-team care between establishments View source Lack of national guidance for management and operational staff on pre-transfer prisoner handover View source Lack of consultation with receiving-prison healthcare teams about care capability View source
Lack of national guidance for healthcare handover to receiving prisons View source Delays in transferring prisoners requiring mental health hospital admission View source Lack of guidance requiring consultation with prison doctors before transferring prisoners receiving medical care View source Failure of the email-a-prisoner system to facilitate contact after unrecognised prisoner transfers View source See 4 more concerns
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England Unilink Software Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Department of Health and Social Care
Work with NHS England and His Majesty’s Prison and Probation Service to respond to concerns about delays transferring mentally unwell prisoners to hospital.
View source
Department of Health and Social Care
Review the response to the thematic review and monitor progress in addressing delays transferring mentally unwell prisoners to hospital.
View source
Department of Health and Social Care
Introduce the Mental Health Bill during the current Parliamentary session.
View source
NHS England
Respond directly to concerns identified in the thematic review of delays transferring mentally unwell prisoners.
View source
NHS England
Use a clinical template to record and monitor referrals, assessments and transfers under sections 47 and 48 of the Mental Health Act.
View source
NHS England
Gather transfer-timeliness data and work with commissioners to improve the quality and completeness of existing data collection.
View source
NHS England
Review mental health pathway processes, communication and information sharing, then develop a proposed pathway and programme plan addressing identified gaps and priorities.
View source
Unilink Software Limited
Raise prisoner-movement communication issues with the Ministry of Justice and explore confidentially sharing relevant movement information to support timely message redirection.
View source See 5 more actions
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AI-generated summary
Frazer Charlie Williams · 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
Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.
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 guidance on transferring prisoners under healthcare-team care between establishments
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold . There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” Source location Frazer Charlie Williams · Prevention of Future Deaths report
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 Lack of national guidance for management and operational staff on pre-transfer prisoner handover
Wider context from the report “vi. There is lack of national guidance for both senior management and operational prison staff in relation to the handover of a prisoner in advance of their transfer , not specific to, but especially those with complex needs, when transferring between prisons.
” Source location Frazer Charlie Williams · Prevention of Future Deaths report
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 Lack of consultation with receiving-prison healthcare teams about care capability
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person .
” Source location Frazer Charlie Williams · Prevention of Future Deaths report
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 Lack of national guidance for healthcare handover to receiving prisons
Wider context from the report “iv. There is a lack of national guidance for healthcare teams working in prisons around the handover of healthcare of a prisoner to the receiving prison when they are transferred to another prison.
” Source location Frazer Charlie Williams · Prevention of Future Deaths report
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 transferring prisoners requiring mental health hospital admission
Wider context from the report “i. There is inequity within the system of the treatment of a person with mental illness in the prison setting compared to an individual in the community, due to the fact that in the community a person would be placed in a hospital setting on the day they were deemed to require hospital admission, however in prison there are delays in transferring a prisoner in the same situation to hospital .
” Source location Frazer Charlie Williams · Prevention of Future Deaths report
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 Lack of guidance requiring consultation with prison doctors before transferring prisoners receiving medical care
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care , whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold . Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” Source location Frazer Charlie Williams · Prevention of Future Deaths report
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 of the email-a-prisoner system to facilitate contact after unrecognised prisoner transfers
Wider context from the report “xiv. The email a prisoner system is dependant on the person wanting to contact the prisoner knowing their location , so if the prisoner is transferred to another prison and the person contacting them is not aware, contact which can be a protective factor particularly in a prisoner’s mental health care, will not be facilitated.
” Source location Frazer Charlie Williams · Prevention of Future Deaths report
Open source report
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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 NHS England and His Majesty’s Prison and Probation Service to respond to concerns about delays transferring mentally unwell prisoners to hospital.
Verbatim wording from the response “I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.” Source location Response from DHSC
Open published response
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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 the response to the thematic review and monitor progress in addressing delays transferring mentally unwell prisoners to hospital.
Verbatim wording from the response “I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.” Source location Response from DHSC
Open published response
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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 Introduce the Mental Health Bill during the current Parliamentary session.
Verbatim wording from the response “In addition to this, the Mental Health Bill will be introduced in this Parliamentary session. The Bill sets out vital reforms to support people with severe mental illness in the criminal justice” Source location Response from DHSC
Open published response
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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 Respond directly to concerns identified in the thematic review of delays transferring mentally unwell prisoners.
Verbatim wording from the response “I would like to reassure you that NHS England consistently strives for equality in mental health healthcare provision. To address the specific concerns about Frazer’s care, there are several cross party workstreams underway.” Source location Response from NHS England
Open published response
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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 a clinical template to record and monitor referrals, assessments and transfers under sections 47 and 48 of the Mental Health Act.
Verbatim wording from the response “A new clinical template for improving data collection and monitoring has been developed and is now in place, to record the referral, assessment and transfer process for prisoners and detainees, under sections 47 and 48 of the Mental Health Act (MHA)” Source location Response from NHS England
Open published response
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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 Gather transfer-timeliness data and work with commissioners to improve the quality and completeness of existing data collection.
Verbatim wording from the response “1983. This template is for use within the health and justice information system (HJIS) in prisons (current SystemOne). NHS England is working to use the information generated to gather data on the timeliness of transfers, whilst also proactively working with Health and Justice commissioners to improve data quality and completeness of existing manual collection.” Source location Response from NHS England
Open published response
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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 mental health pathway processes, communication and information sharing, then develop a proposed pathway and programme plan addressing identified gaps and priorities.
Verbatim wording from the response “A review of processes, communication and information sharing around mental health concerns is also underway and will be completed by February 2025. This review is calling “Health and Justice Mental Health Pathway”. Work on the development of a Mental Health Pathway aims to:” Source location Response from NHS England
Open published response
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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 Raise prisoner-movement communication issues with the Ministry of Justice and explore confidentially sharing relevant movement information to support timely message redirection.
Verbatim wording from the response “We fully recognize the importance of ensuring that such communications reach their intended recipients, particularly in situations like this, and we deeply regret any distress this may have caused. To prevent similar occurrences in the future, we will raise this issue with the Ministry of Justice and explore whether there is a possibility of confidentially sharing relevant information about prisoner movements, which could help to better manage and redirect communications in a timely manner.” Source location Response from Unilink
Open published response
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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 Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.
Verbatim wording from the response “With regard to the other concerns you have raised around a lack of national guidance relating to a range of healthcare issues in prison settings; operational issues regarding the ACCT process and engagement with prisoners’ family members, I would expect the other recipients of your report to address these in their responses, as they are responsible for matters relating to day to day operations within prison settings. I look forward to seeing their responses and working with them where appropriate, to avoid a repetition of the horrific events of this case.” Source location Response from DHSC
Open published response
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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 HMPPS should respond to the absence of a national prison healthcare directory and related prisoner-transfer guidance.
Verbatim wording from the response “i. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold.” Source location Response from NHS England
Open published response
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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 leads the response to delays transferring mentally unwell prisoners to hospital, with the Department reviewing progress.
Verbatim wording from the response “I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.” Source location Response from DHSC
Open published response
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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 Without access to prisoner movement information, the service could not redirect the message or notify the sender of the transfer.
Verbatim wording from the response “However, we now understand that Frazer was moved to HMP Guys March on 14th January, and it is therefore unlikely that he received this last message. As you may know, Unilink does not have access to prison rolls or prisoner movement information for security reasons. This is expected to be known by the person contacting them. In this case neither the sender nor Unilink was aware of Frazer’s transfer and hence were unable to take any action to redirect the message or notify the sender of the situation.” Source location Response from Unilink
Open published response
21 Mar 2024 Alan Richard Miles Davies · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2
Failure to provide agency staff with sufficient information for informed reception support View source Failure to accompany transfers with Caswell Clinic staff View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Alan Richard Miles Davies · 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
Alan Richard Miles Davies was transferred to HMP Cardiff after 16 days of refusing food and was found collapsed in his cell 10 days later; he later died in hospital. The reported concerns included inadequate communication and handover of information, insufficient care planning and observation, the absence of a food and fluid refusal policy, inadequate staffing, and missed opportunities to escalate his care.
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 provide agency staff with sufficient information for informed reception support
Wider context from the report “(3) Mr Davies was transferred to prison without being accompanied by a member of Caswell Clinic staff. Agency staff did not have sufficient information to be able to assist prison reception staff in an informed manner
” Source location Alan Richard Miles Davies · Prevention of Future Deaths report
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 accompany transfers with Caswell Clinic staff
Wider context from the report “(3) Mr Davies was transferred to prison without being accompanied by a member of Caswell Clinic staff . Agency staff did not have sufficient information to be able to assist prison reception staff in an informed manner
” Source location Alan Richard Miles Davies · Prevention of Future Deaths report
Open source report
4 Jan 2024 Stephen COSTER · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1
Inadequate understanding among prison staff of the local policy for emergency hospital transfer with retrospective risk assessment View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Stephen COSTER · 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
Stephen Coster died from meningoencephalitis owing to Streptococcus pneumoniae after becoming seriously unwell while detained at HMP Lewes. The inquest found delays in providing treatment and transferring him to hospital, with concerns including inadequate observations and assessment, poor record keeping, failures to escalate, and breakdowns in communication and leadership between prison and healthcare staff.
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 understanding among prison staff of the local policy for emergency hospital transfer with retrospective risk assessment
Wider context from the report “f. An inadequate understanding amongst prison staff about the local policy to transfer emergency cases to hospital with a retrospective risk assessment .
” Source location Stephen COSTER · Prevention of Future Deaths report
Open source report
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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 Actively review the emergency-escort policy.
Verbatim wording from the response “Custodial Managers have the authority to dispatch an emergency escort without the relevant risk assessment where the life of a prisoner is in danger. The Local Operating Procedure for Hospital Escorts and Bedwatches refers to escorts being dispatched without the relevant risk assessment where there is an ‘emergency.’ The policy on emergency escorts as a whole is being actively reviewed.” Source location Response from HM Prison and Probation Service
Open published response
Concerns raised 1
Failure to ensure transfer for psychiatric treatment where required View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Martin Samuel WILLIS · 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
Martin Samuel Willis was a serving prisoner at HMP Stoke Heath when he was found hanging in his cell on 15 September 2022. He was on the suicide and self-harm prevention scheme, but concerns included failures in observation recording and supervision, uncertainty about the appropriate observation level and possible transfer for mental health treatment, and the need for a collective review of the care provided.
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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 transfer for psychiatric treatment where required
Wider context from the report “3. Overriding issues remain as to whether or not the late Mr Willis was on the correct levels of observation up to constant watch and whether he should have been transferred to an psychiatric grounds for treatment at another prison establishment with a hospital wing .
” Source location Martin Samuel WILLIS · Prevention of Future Deaths report
Open source report
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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 Discuss reviewing the standard operating procedure for referring and transferring prisoners to establishments with hospital wings.
Verbatim wording from the response “Action 3. In addition to the above actions the Midlands Partnership University NHS Foundation Trust have commenced discussions with NHS England regarding a review of their Standard Operating Procedure concerning the referral of and transfer of prisoners to prison establishments with a hospital wing which was an agreed outcome of the inter-agency review. Completion timescale September 2024.” Source location Response from Midlands Partnership University
Open published response
12 Oct 2023 Mr Jonathan Michael McCarthy · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1
Failure to assess fitness to transfer View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Practice Plus Group
Undertake and record a fitness-to-transfer assessment for every patient before transfer to an establishment or court.
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AI-generated summary
Mr Jonathan Michael McCarthy · 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 Jonathan Michael McCarthy died on 12 August 2018 at University Hospital Coventry and Warwickshire from a cardiac arrhythmia associated with scarring of the heart, while at HMP Onley. Concerns included failures to verify and assess the clinical importance of pre-existing community hospital appointments, the impact of security issues on those appointments, and whether he was fit to transfer or should have been placed on medical hold.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to assess fitness to transfer
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” Source location Mr Jonathan Michael McCarthy · Prevention of Future Deaths report
Open source report
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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 Undertake and record a fitness-to-transfer assessment for every patient before transfer to an establishment or court.
Verbatim wording from the response “All patients will have a fitness to transfer assessment undertaken prior to transfer to any establishment or court, this is recorded on SystmOne and forms part of the transfer process. Healthcare are generally notified 24 hours prior to release or transfer of a patient. This can vary depending on external factors such as Court listings and timings.” Source location Response from Practice Plus Group
Open published response
3 Jul 2023 Andre Felipe Mendes Moura · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to require body worn video during prisoner escorts nationally View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Andre Felipe Mendes Moura · 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
Andre Moura died on 7 July 2018 after suffering cardiac arrest in a police vehicle while under arrest and being transported following a significant struggle. The report identified concerns about officers’ recognition and training in acute behavioural disturbance, use of objective responsiveness checks, the safety officer role, and the absence of body-worn camera recording during escort.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to require body worn video during prisoner escorts nationally
Wider context from the report “5. The officers escorting Mr Moura to the police station did not have their body worn cameras on. Greater Manchester Police (GMP) at the time did not have a policy at that time requiring escorting officers to switch on their Body Worn Video (BWV) cameras. GMP do now require that BWV cameras are on. This is an important change but it was not clear if all forces have implemented such a change . Given that the evidence before the inquest made it clear that the change in practice by GMP was important in allowing clarity around how a prisoner is behaving whilst being escorted to custody it is important that its use at all times should be promoted nationally .
” Source location Andre Felipe Mendes Moura · Prevention of Future Deaths report
Open source report
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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 and publish NPCC body-worn video guidance requiring recording during prisoner transport and addressing coverage, access and retention of journey footage.
Verbatim wording from the response “In relation to point 5, we are in the process of re-writing and revising the NPCC Body Worn Video (BWV) guidance and it has been agreed that we would include that BWV should be left running during periods of prisoner transport, due to the vulnerability of officers and subjects during that process, and to provide a documented account of that journey. This guidance will be published in October, and I share the relevant draft wording below:” Source location Response from National Police Chief's Council
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.