Recurring concern

Failure to ensure safe prisoner transfers

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First reported 6 Jan 2014•Latest report 9 Feb 2026

Definition

What this concern includes

Includes failures of controls dedicated to the prisoner transfer process, including pre-transfer risk assessment, transfer handover and information sharing, receiving-prison checks, and continuity of essential prisoner support.

Not included

Excludes generic staffing, training, documentation or communication deficiencies unless they are specifically tied to the safety of a prisoner transfer.
Excludes failures concerning prisoner supervision or care that are unrelated to a transfer.
Excludes general deficiencies in prison healthcare or custody operations without a transfer-specific connection.

Reports: 26
Individual concerns: 43
Date range: 2014–2026
Stated actions: 62

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service11

Ministry of Justice11

NHS England7

Department of Health and Social Care5

Greater Manchester Police2

Oxleas NHS Foundation Trust2

Practice Plus Group2

Serco Group plc2

Bedford Prison1

Belmarsh Prison1

Cardiff Prison1

Cardiff & Vale University LHB1

College of Policing1

Cookham Wood Prison1

G4S1

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.

30 Sep2021
Inner South London
Concerns raised1
1. Premature closure of ACCTs for newly transferred prisoners before sufficient review, assessment and communication
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement ACCT version 6 across the prison estate, strengthening multidisciplinary reviews, information sharing, support-action oversight, post-closure monitoring and transfer procedures.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Share a learning bulletin with all establishments and publish it on the HMPPS intranet to improve communication and information sharing when transferring prisoners on open ACCTs.
  Stated by HM Prison and Probation ServiceStated completed
Respondent positions 3
1. Position
  Responsibility for the ACCT process lies with HMPPS, which has responded on this matter.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  ACCT processes are sufficient, so a mandatory period before closing an ACCT should not be imposed.
  Stated by HM Prison and Probation ServiceExisting arrangements considered sufficient
2. Position
  Effective ACCT risk assessment and completed support actions make mandatory monitoring after transfer on an open ACCT unnecessary.
  Stated by HM Prison and Probation ServiceExisting arrangements considered sufficient
AI-generated summary

Stephen David COPE · 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 David Cope died by suspension in his own cell block at Belmarsh prison on 18 November 2019. The principal concern was the transfer and review of prisoners on an ACCT, particularly the closure of an ACCT shortly after a prisoner’s transfer before support services had sufficient time to assess and communicate about them.

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
Premature closure of ACCTs for newly transferred prisoners before sufficient review, assessment and communication
Wider context from the report
“(1) The transfer and review of prisoners on an ACCT. I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her. For ACCTs created on current inmates within an establishment, who are known to staff, I do not see that as an issue, they would already have an existing knowledge and relationship and indeed would have been the originator of the ACCT in any event. However, for new prisoners, who have arrived from another prison establishment with an open ACCT on their record, I consider the ability to remove that individual from the ACCT, within a short period of time, does raise issues in respect of the knowledge and understanding of that individual and the ability of various agencies, within the prison, to have had time to review and communicate between themselves, about that individual. The provision of in effect 2 ‘no’ answers by a prisoner, is a potentially easy way of coming off an ACCT, which is there for their support and well-being, and I would suggest, given to easy manipulation I raise the issue as to whether there should be, for example, a set review period (e.g. 7 days) which allows time for the support services to meet with and interview the transferred inmate, interact, and then make a decision about and with the newly transferred prisoner on the ACCT before such an ACCT is closed. ”
Source location
Stephen David COPE · 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
Implement ACCT version 6 across the prison estate, strengthening multidisciplinary reviews, information sharing, support-action oversight, post-closure monitoring and transfer procedures.

Verbatim wording from the response
“You may be aware that HMPPS has developed a revised version of ACCT, known as ACCT version 6, (ACCT V6) that was implemented across the prison estate in July 2021. The changes introduced in this new version are intended to assist staff to provide high quality multi-disciplinary care and support to individuals at risk, focusing on a person-centred approach which meets the needs of each individual. Some of the key changes include an emphasis on information sharing, improved case reviews and a strengthened post-closure period.”

Source location
2021-0332-Response-from-HMPPS_Published
Page 1 · response
Published 13 October 2021
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
Share a learning bulletin with all establishments and publish it on the HMPPS intranet to improve communication and information sharing when transferring prisoners on open ACCTs.

Verbatim wording from the response
“A learning bulletin about transferring prisoners on an open ACCT which emphasises the importance of good communication and information-sharing has been shared with all establishments and is available on the HMPPS intranet.”

Source location
2021-0332-Response-from-HMPPS_Published
Page 2 · response
Published 13 October 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Responsibility for the ACCT process lies with HMPPS, which has responded on this matter.

Verbatim wording from the response
“Responsibility for the Assessment, Care in Custody and Teamwork (ACCT) process lies with HMPPS and I am aware that it has responded to you on this matter. A new version of the ACCT has been introduced with changes that include an increased emphasis on information sharing, strengthened case reviews and post-closure procedures. In particular, I note that updated guidance accompanying the ACCT makes clear that when a change of circumstance takes place, such as transfer to another prison, an urgent case review must take place, prior to transfer, and as soon as possible at the receiving prison, informed by handover.”

Source location
2021-0332-Response-from-Department-of-Health-Social-Care_Published
Page 2 · response
Published 13 October 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
ACCT processes are sufficient, so a mandatory period before closing an ACCT should not be imposed.

Verbatim wording from the response
“As a key aim of ACCT is to focus on the needs of the individual, we do not believe that it is appropriate to mandate a period during which an ACCT cannot be closed. However, I wish to assure you that the processes in place work to provide the support needed in order to reduce the risk of self-harm and suicide and to ensure that an ACCT is not closed until it is considered safe to do so.”

Source location
2021-0332-Response-from-HMPPS_Published
Page 1 · response
Published 13 October 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Effective ACCT risk assessment and completed support actions make mandatory monitoring after transfer on an open ACCT unnecessary.

Verbatim wording from the response
“Therefore, if the process is followed effectively and defensible decisions are made based on effective risk assessment then a mandatory period of monitoring for those who transfer on an open ACCT should not be required. The ACCT document will not be closed until all support actions have been completed and there is multi-disciplinary agreement that the level of risk has reduced.”

Source location
2021-0332-Response-from-HMPPS_Published
Page 2 · response
Published 13 October 2021
Open published response
17 Sep2021
Worcestershire
Concerns raised1
1. Failure to hold an ACCT Case Review immediately before transfer
This report raised 17 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Colin BLACKBURN · 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

Colin Blackburn died at HMP Hewell on 6 July 2019 after spending 15 days on remand and having been found with a ligature around his neck on three prior occasions. Concerns included multiple accepted failings in the management of his ACCT suicide and self-harm risk, and uncertainty about the correct process for urgent mental-health referrals, particularly at weekends.

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 hold an ACCT Case Review immediately before transfer
Wider context from the report
“1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service: (a) that no Initial ACCT Case Review was held within 24 hours of the Concern; (b) that no entries were made on the Care Map until 26.6.19; (c) that no triggers or warning signs have been entered on the ACCT’s inside cover; (d) that no ACCT Case Manager was assigned until 26.6.19; (e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19; (f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend; (g) that the Care Map was not reviewed at some ACCT Case Reviews; (h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand; (i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out; (j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; (k) that no ACCT Case Review took place after the first ligature incident on 2.7.19; (l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5; (m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and (n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19. ”
Source location
Colin BLACKBURN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Apr2020
Lancashire and Blackburn with Darwen
Concerns raised5
1. Failure to record transfer decisions and pre-transfer checks
2. Failure to assess risk before prisoner transfer
3. Failure to interview transferred prisoners and provide distraction materials on reception
1. Failure to provide receiving wings with relevant prisoner risk information during transfer handover
2. Failure to assess risk on reception and after transfer
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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 record transfer decisions and pre-transfer checks
Wider context from the report
“b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera; d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer; e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death; g. Inconsistent medication regimes without explanation; h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred; i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place; j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime. ”
Source location
Andrew Patrick Jones · Prevention of Future Deaths report
Page 7 · 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 assess risk before prisoner transfer
Wider context from the report
“b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera; d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer; e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death; g. Inconsistent medication regimes without explanation; h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred; i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place; j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime. ”
Source location
Andrew Patrick Jones · Prevention of Future Deaths report
Page 7 · 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 interview transferred prisoners and provide distraction materials on reception
Wider context from the report
“Finally, although SO ████████, the SO on C Wing would have liked more information, he neither asked the transferring wing SO for this nor interviewed Andrew Jones when he arrived on C Wing. No adequate interview was undertaken on C Wing of Andrew Jones before his death despite the fact he was segregated nor were any distraction materials provided. ”
Source location
Andrew Patrick Jones · Prevention of Future Deaths report
Page 4 · 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 provide receiving wings with relevant prisoner risk information during transfer handover
Wider context from the report
“The only handover that was given by SO ████████ on the RSU to the receiving wing was that there were no non-associates and Andrew Jones was behind his door on basic regime pending adjudication. SO ████████ was unaware that Andrew Jones had been on an ACCT until after he had been sent to C Wing. ”
Source location
Andrew Patrick Jones · Prevention of Future Deaths report
Page 2 · 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 assess risk on reception and after transfer
Wider context from the report
“b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera; d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer; e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death; g. Inconsistent medication regimes without explanation; h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred; i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place; j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime. ”
Source location
Andrew Patrick Jones · Prevention of Future Deaths report
Page 8 · concerns
Open source report
20 Dec2019
Manchester City
Concerns raised5
1. Inappropriate minimisation of prisoners’ illness or vulnerability during transfer decisions
2. Failure to provide coordinated interpreted communication about prisoner transfers
3. Failure of staff to understand transfer rationale and destination suitability
1. Failure to ensure prisoners understand transfer reasons and destination regimes
2. Failure of receiving-wing staff to attend final ACCT case reviews before transfer
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Improve interpretation-service use at HMP Manchester by providing conference-style telephones for case reviews.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Complete changes to the redesigned ACCT form and guidance and roll them out across the prison estate.
  Stated by HM Prison and Probation ServiceStated in progress
3. Action
  Hold and document ACCT case reviews before prisoner location moves, with receiving-location representation and transfer of relevant information.
  Stated by HM Prison and Probation ServiceStated completed
Respondent positions 1
1. Position
  The healthcare provider is responsible for responding separately to concerns about clinical issues.
  Stated by HM Prison and Probation ServiceRedirects responsibility
AI-generated summary

Tomasz Nowosad · 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

Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by 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
Inappropriate minimisation of prisoners’ illness or vulnerability during transfer decisions
Wider context from the report
“5 16 It is suggested that it is not appropriate to indicate to a patient prisoner that they are not so ill or vulnerable as others in considering a move out of the HCC because that may influence their cooperation and disclosure of their symptoms and presentation It is suggested that guidance is issued to GMMH staff about this ”
Source location
Tomasz Nowosad · Prevention of Future Deaths report
Page 7 · 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 provide coordinated interpreted communication about prisoner transfers
Wider context from the report
“5 15 It is suggested that it is not appropriate for GMMH clinical or Nursing Staff to put the onus or responsibility on a prisoner to interact with HMPS staff to try and understand why they may be moving from one location to another without both being present and the language line service used to try and ensure no miscommunication and that appropriate written guidance should be given to all staff ”
Source location
Tomasz Nowosad · Prevention of Future Deaths report
Page 7 · 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 of staff to understand transfer rationale and destination suitability
Wider context from the report
“5 10 It is suggested that GMMH and HMPS staff should ensure as is far as is reasonably possible that the patient prisoner has a real understanding and comprehension of the reasons for transfer and the regime to which they are going, particularly if they have been moved from the HCC when they occupied a safer cell but were going to an ordinary cell with a number of ligature points The staff themselves have to have a clear understanding of the reasons for transfer and what the new wing regime or locations means for the prisoner and whether or not it is appropriate Records should be kept of the reasoning and justification ”
Source location
Tomasz Nowosad · Prevention of Future Deaths report
Page 7 · 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 ensure prisoners understand transfer reasons and destination regimes
Wider context from the report
“5 10 It is suggested that GMMH and HMPS staff should ensure as is far as is reasonably possible that the patient prisoner has a real understanding and comprehension of the reasons for transfer and the regime to which they are going, particularly if they have been moved from the HCC when they occupied a safer cell but were going to an ordinary cell with a number of ligature points The staff themselves have to have a clear understanding of the reasons for transfer and what the new wing regime or locations means for the prisoner and whether or not it is appropriate Records should be kept of the reasoning and justification ”
Source location
Tomasz Nowosad · Prevention of Future Deaths report
Page 7 · 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 of receiving-wing staff to attend final ACCT case reviews before transfer
Wider context from the report
“5 8 It is suggested that whenever there is a decision made to move a prisoner who is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues ”
Source location
Tomasz Nowosad · Prevention of Future Deaths report
Page 7 · 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
Improve interpretation-service use at HMP Manchester by providing conference-style telephones for case reviews.

Verbatim wording from the response
“Second, interpretation services (5.4). You express concern about inconsistent use of such services by staff. A national contract with The Big Word ensures the availability of interpretation services across the prison estate. The new ACCT guidance will emphasise the importance of their use throughout the process, and the new ACCT form will include prompts to consider the use of the service at every significant point, including assessments and case reviews. In advance of the roll out of the new version of ACCT, the Governor of HMP Manchester has taken action to improve the use of the service at the prison, for example by making conference style telephones available for use at case reviews.”

Source location
2019-0445-Response-from-HMPPS
Page 2 · response
Published 8 January 2020
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
Complete changes to the redesigned ACCT form and guidance and roll them out across the prison estate.

Verbatim wording from the response
“A number of your concerns relate to the Assessment, Care in Custody and Teamwork (ACCT) case management process for those identified as being at risk of self-harm or suicide. We have been working hard to improve the way that this system operates. Following a comprehensive review, we have devised a new version of the form and associated guidance, and I am pleased to note that much of what you have suggested has been adopted as part of that. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was piloted in ten establishments in 2019 and the feedback has been positive. We are currently making some further changes before rolling it out across the prison estate later in 2020.”

Source location
2019-0445-Response-from-HMPPS
Page 1 · response
Published 8 January 2020
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
Hold and document ACCT case reviews before prisoner location moves, with receiving-location representation and transfer of relevant information.

Verbatim wording from the response
“The new ACCT guidance is much clearer about the need to involve the prisoner in all decisions that are taken, including those concerning location. In advance of implementing the new system, it is now the practice at HMP Manchester for a case review to be held prior to any location move, including moves from healthcare to residential wings. These reviews are attended by a representative from the new location, providing an opportunity to discuss any concerns and issues relating to risk, including how a change to location and regime might affect risk. Notes of the review and any decisions made are recorded in both the ACCT document and in the NOMIS case notes. Where an enhanced assessment has been completed by the psychology department, this is also forwarded to the new location.”

Source location
2019-0445-Response-from-HMPPS
Page 2 · response
Published 8 January 2020
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 healthcare provider is responsible for responding separately to concerns about clinical issues.

Verbatim wording from the response
“I am grateful to you for bringing to my attention a number of matters of concern, many of which are relevant across the prison estate. I have consulted with the Governor of HMP Manchester and, where relevant, will mention action that has been taken locally at the prison as well as work that is taking place at national level. I understand that the healthcare provider is responding separately to your concerns about clinical issues.”

Source location
2019-0445-Response-from-HMPPS
Page 1 · response
Published 8 January 2020
Open published response
23 Jul2019
Manchester South
Concerns raised1
1. Failure to search prisoners before transport
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Deliver Transportation of Detained Persons procedure content in the foundation course for all newly appointed Student Police Officers.
  Stated by Greater Manchester PoliceStated completed
2. Action
  Review and incorporate relevant transportation-procedure components into annual Personal Safety Training for operational police officers and staff.
  Stated by Greater Manchester PoliceStated in progress
AI-generated summary

Adam Harris · 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

Adam Harris died at Tameside General Hospital on 20 April 2018 from alcohol and cocaine toxicity after collapsing at Ashton Police Station following his arrest and detention. Concerns included the absence of documented triage or risk assessment while prisoners waited in the van dock, lack of searches before transport, unclear handover arrangements, delayed creation of the custody record, and inconsistent evidence about his position in the cell while confused and suspected to be intoxicated.

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 search prisoners before transport
Wider context from the report
“2. Adam Harris was not arrested until he was in the rear of the Police van. None of the officers present searched him before he was placed in the van or before he was transported to Ashton Police Station; ”
Source location
Adam Harris · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver Transportation of Detained Persons procedure content in the foundation course for all newly appointed Student Police Officers.

Verbatim wording from the response
“From August 2019 the contents of the revised “Transportation of Detained Persons” procedure features in the initial Student Police Officer foundation training course delivered to all Student Police Officers on appointment. There are also components of the policy currently being reviewed with a view to being incorporated into the Personal Safety Training courses which all operational Police Officers and staff undertake annually. It is anticipated that the revised training will commence in Autumn / Winter 2019.”

Source location
2019-0247-Response-from-Greater-Manchester-Police
Page 2 · response
Published 9 September 2019
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
Review and incorporate relevant transportation-procedure components into annual Personal Safety Training for operational police officers and staff.

Verbatim wording from the response
“From August 2019 the contents of the revised “Transportation of Detained Persons” procedure features in the initial Student Police Officer foundation training course delivered to all Student Police Officers on appointment. There are also components of the policy currently being reviewed with a view to being incorporated into the Personal Safety Training courses which all operational Police Officers and staff undertake annually. It is anticipated that the revised training will commence in Autumn / Winter 2019.”

Source location
2019-0247-Response-from-Greater-Manchester-Police
Page 2 · response
Published 9 September 2019
Open published response
31 Jan2019
Birmingham and Solihull
Concerns raised1
1. Failure to review information about prisoners entering the prison
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Andrew Stephen 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

Andrew Stephen Carr, a prisoner, was found unresponsive in his cell on 29 March 2018 and was pronounced dead at 22:53 after attempts to revive him were unsuccessful. The medical cause of death was recorded as the effects of a synthetic cannabinoid. Concerns included failures to identify and record information about his prior substance use, the known use of the prison plumbing system to pass drugs, and the role of contraband mobile phones in substance misuse.

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 review information about prisoners entering the prison
Wider context from the report
“1. The inquest heard evidence that before his transfer to Birmingham prison on 19/02/18 Andrew had been involved in 4 incidents of taking psychoactive substances resulting in a code blue being called. In addition there was intelligence that he may be giving out drugs. This information was available and passed onto Birmingham Prison - however they were not aware of it and did not record the information. The inquest heard that there was no time to review information of prisoners coming into the prison. This is a major concern as key information may not be identified and this poses a risk to the individual and other prisoners. ”
Source location
Andrew Stephen Carr · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Dec2018
Surrey
Concerns raised1
1. Delays in transferring prisoners to secure hospitals under s.47 of the Mental Health Act 1983
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Complete the review of guidance on prisoner transfer and remission under sections 47 and 48 of the Mental Health Act.
  Stated by NHS EnglandStated completed
2. Action
  Submit revised prisoner transfer and remission guidance for public consultation.
  Stated by NHS EnglandStated planned
3. Action
  Implement the revised prisoner transfer and remission guidance nationally after consultation.
  Stated by NHS EnglandStated planned
1. Action
  Conduct annual audits benchmarking prisoner transfer and remission data, including the current audit cycle.
  Stated by NHS EnglandStated in progress
2. Action
  Develop improved performance management through increased collection and analysis of transfer pathway data.
  Stated by NHS EnglandStated in progress
3. Action
  Disseminate identified good-practice examples from prison-to-mental-health transfer pathways nationally.
  Stated by NHS EnglandStated in progress
4. Action
  Conduct demand and capacity reviews for adult high-, medium- and low-secure mental health services.
  Stated by NHS EnglandStated in progress
5. Action
  Roll out nationally the provider-led management of adult medium- and low-secure service budgets and whole-pathway responsibility.
  Stated by NHS EnglandStated planned
6. Action
  Develop a prison transfer service within a secure inpatient service to provide dedicated transfer and remission capacity.
  Stated by NHS EnglandStated in progress
Respondent positions 4
1. Position
  The report does not establish the extent to which delayed transfer contributed to the death.
  Stated by Department of Health and Social CareDisputes the concern
1. Position
  NHS England is responsible for commissioning prison healthcare and secure mental health beds, so it must respond in detail.
  Stated by Department of Health and Social CareRedirects responsibility
2. Position
  The Mental Health Act sets no transfer deadline, and the proposed 14-day target was guidance rather than an accepted statutory requirement.
  Stated by NHS EnglandDisputes the concern
3. Position
  Secondary mental health providers and CCGs hold responsibility for planning or commissioning relevant local mental health pathways and beds.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Miss Kirsty Walker · 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

Miss Kirsty Walker died in hospital on 27 September 2015 after being found unresponsive in prison with a ligature tied around her neck. She had a history of self-harm and had engaged in 235 acts of self-harm during her imprisonment, including 215 involving ligatures. The report raised concern that prisoners were taking well over 14 days to transfer to secure hospitals under section 47 of the Mental Health Act 1983, presenting a risk of further 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
Delays in transferring prisoners to secure hospitals under s.47 of the Mental Health Act 1983
Wider context from the report
“I am concerned that the average time to transfer a prisoner to a secure hospital under s.47 of the Mental Health Act 1983 is well in excess of the 14 days envisaged by the 2009 Bradley Report and presents a risk of further deaths. ”
Source location
Miss Kirsty Walker · 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
Complete the review of guidance on prisoner transfer and remission under sections 47 and 48 of the Mental Health Act.

Verbatim wording from the response
“NHS England has regard to the above Good Practice Guide in relation to transfer times from prison to mental health inpatient services and is now responsible for reviewing the Good Practice Guide. The aim of the review is to provide for more clinically informed timescales for the transfer and remission of prisoners to and from mental health hospital. This revised document has been developed with stakeholders and is currently being prepared in readiness for public consultation which is anticipated to take place early in 2019.”

Source location
2018-0396-Response-by-NHS-England
Page 2 · response
Published 17 May 2019
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
Submit revised prisoner transfer and remission guidance for public consultation.

Verbatim wording from the response
“NHS England has regard to the above Good Practice Guide in relation to transfer times from prison to mental health inpatient services and is now responsible for reviewing the Good Practice Guide. The aim of the review is to provide for more clinically informed timescales for the transfer and remission of prisoners to and from mental health hospital. This revised document has been developed with stakeholders and is currently being prepared in readiness for public consultation which is anticipated to take place early in 2019.”

Source location
2018-0396-Response-by-NHS-England
Page 2 · response
Published 17 May 2019
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
Implement the revised prisoner transfer and remission guidance nationally after consultation.

Verbatim wording from the response
“As above a review of the Good Practice Guidance 2011 has taken place, led by NHS England. The revised guidance will be submitted for public consultation prior to implementation nationally, and will consider the whole process of referral, assessment, transfer and remission.”

Source location
2018-0396-Response-by-NHS-England
Page 4 · response
Published 17 May 2019
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 annual audits benchmarking prisoner transfer and remission data, including the current audit cycle.

Verbatim wording from the response
“1. An annual audit benchmarking data in relation to the transfer and remission process;”

Source location
2018-0396-Response-by-NHS-England
Page 3 · response
Published 17 May 2019
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
Develop improved performance management through increased collection and analysis of transfer pathway data.

Verbatim wording from the response
“2. Improved performance management through increased and improved collection and analysis of data;”

Source location
2018-0396-Response-by-NHS-England
Page 3 · response
Published 17 May 2019
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
Disseminate identified good-practice examples from prison-to-mental-health transfer pathways nationally.

Verbatim wording from the response
“In respect to the improved performance management and capability that is being developed in this area, good practice examples relating to the pathway between prisons and respective mental health inpatient services are being identified in some parts of the country and processes to disseminate and share this information nationally is a specific focus.”

Source location
2018-0396-Response-by-NHS-England
Page 4 · response
Published 17 May 2019
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 demand and capacity reviews for adult high-, medium- and low-secure mental health services.

Verbatim wording from the response
“3. A demand and capacity review in relation to adult high, medium and low-secure services;”

Source location
2018-0396-Response-by-NHS-England
Page 3 · response
Published 17 May 2019
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
Roll out nationally the provider-led management of adult medium- and low-secure service budgets and whole-pathway responsibility.

Verbatim wording from the response
“4. An initiative was proposed in December 2015 and then piloted from 2016, where mental health care providers were encouraged to take on the management of tertiary budgets for adult medium and low secure services and were able to work in partnership with other providers to enable the local system to be responsive and take ownership of the whole pathway including where that related to prison transfers. In February 2018 it was agreed that this approach would be rolled out nationally;”

Source location
2018-0396-Response-by-NHS-England
Page 3 · response
Published 17 May 2019
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
Develop a prison transfer service within a secure inpatient service to provide dedicated transfer and remission capacity.

Verbatim wording from the response
“Another example of good practice is the development of a prison transfer service within a secure inpatient service. This service focuses specifically on transfers from prison, enabling timely transfers and remission where appropriate to ensure that particular capacity is used exclusively for this patient group.”

Source location
2018-0396-Response-by-NHS-England
Page 4 · response
Published 17 May 2019
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 report does not establish the extent to which delayed transfer contributed to the death.

Verbatim wording from the response
“I have noted the concerns raised in your report about the length of time it takes to transfer a prisoner to a secure hospital under section 47 of the Mental Health Act 1983¹ and the risk this poses to future deaths. It is not clear from the detail in the report as to the extent that this was a contributing factor in the death of Miss Walker. However, I acknowledge the evidence given at inquest in relation to this and the cause for concern of future deaths.”

Source location
2018-0396-Response-by-Department-of-Health-and-Social-Care
Page 1 · response
Published 17 May 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NHS England is responsible for commissioning prison healthcare and secure mental health beds, so it must respond in detail.

Verbatim wording from the response
“You issued your report to NHS England as well as the Department. NHS England is responsible for the commissioning of prison health care services and the commissioning of specialist mental health services, including secure adult mental health beds. It is therefore for NHS England to respond to you in detail. However, I am aware of, and hope you will be assured by, the work currently being undertaken by NHS England around improving access to mental health services, including secure inpatient care, for offenders with mental health difficulties.”

Source location
2018-0396-Response-by-Department-of-Health-and-Social-Care
Page 1 · response
Published 17 May 2019
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 Mental Health Act sets no transfer deadline, and the proposed 14-day target was guidance rather than an accepted statutory requirement.

Verbatim wording from the response
“The provisions of the MHA 1983 do not stipulate a timescale within which prisoner transfers from prison to mental health inpatient services must take place.”

Source location
2018-0396-Response-by-NHS-England
Page 2 · response
Published 17 May 2019
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
Secondary mental health providers and CCGs hold responsibility for planning or commissioning relevant local mental health pathways and beds.

Verbatim wording from the response
“Under the HSCA 2012, NHS England has responsibility for the commissioning of healthcare in prisons and the commissioning of adult secure mental health beds, amongst other specialist mental health services. More recently NHS England has devolved responsibility to secondary MH providers in respect of managing budgets and planning for their local populations. These New Care Models (NCMs) comprise of a lead provider arrangement or a collaborative of providers who are responsible for planning the pathway for their local populations in terms of adult medium and low secure services. Clinical Commissioning Groups (CCGs) are responsible for the commissioning of other mental health services, including psychiatric intensive care units (PICU).”

Source location
2018-0396-Response-by-NHS-England
Page 1 · response
Published 17 May 2019
Open published response
30 Nov2018
Manchester North
Concerns raised2
1. Lack of national guidance on late prison transfers and cut-off points
2. Inadequate weekend mental health staffing and risk assessment for late prison transfers
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Instruct Governors not to enter local agreements accepting transferred prisoners on Fridays.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Strengthen first-night procedures by monitoring every new arrival for 72 hours, including random welfare checks during lock-up periods.
  Stated by HM Prison and Probation ServiceStated completed
3. Action
  Open a Challenge Support and Intervention Plan for new prisoners segregated before transfer.
  Stated by HM Prison and Probation ServiceStated completed
1. Action
  Require healthcare staff to notify the Orderly Officer when new arrivals miss appointments and record follow-up actions when prisoners refuse attendance.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Issue HMP Haverigg staff a reminder to confirm transfers with Healthcare so medical records are promptly reassigned and available on arrival.
  Stated by HM Prison and Probation ServiceStated completed
Respondent positions 2
1. Position
  Existing weekday transfer schedules, advance warnings and exceptional weekend transfers are considered sufficient; removing Friday transfers would increase pressure and late arrivals.
  Stated by HM Prison and Probation ServiceExisting arrangements considered sufficient
1. Position
  NHS England is responsible for responding directly to concerns about healthcare processes and mental healthcare provision.
  Stated by HM Prison and Probation ServiceRedirects responsibility
AI-generated summary

Mr Bradley Fraser Brown · 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 Bradley Fraser Brown was a serving prisoner who died in prison on 14 August 2017 after being found suspended by a ligature from a cell light fitting. The report identifies concerns about his late weekend transfer, limited access to healthcare records and assessments, reduced weekend healthcare provision, and the absence of national guidance on late prison transfers.

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 on late prison transfers and cut-off points
Wider context from the report
“1. Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted. There are no mental health nurses available to assess/monitor prisoners over the weekend, thus making late transfers unsafe. The same concern applies, in principle, to public/bank holidays. There are different levels of healthcare at the weekends as compared to weekdays. This gives cause for concern given the inherent susceptibilities with which prisoners frequently present. Transfer itself creates vulnerability that requires additional support, intervention and care and is of particular concern where the transferring prisoner is being held in isolation within the Care and Separation Unit (CSU or ‘Seg’ as it is colloquially known). By virtue of the very different prison regime at the weekends (increased lock up periods/isolation in cells, fewer staff on duty, reduced activities) timely risk assessment is critical in the prevention of self-harm leading to death. Late transfer also risks inadequate assessment where the clinician concerned cannot access the prisoner’s full healthcare record, thus substantially reducing the amount of key information available to them. Where the transferring prisoner has not been seen by Healthcare, other clinicians such as mental health nurses cannot access the healthcare record database. There is no national guidance in relation to late transfers/cut-off points etc. 2. Commissioning of Mental Health/Healthcare Services: As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action. These issues are not unique to the Prison involved in Mr Brown’s case. ”
Source location
Mr Bradley Fraser Brown · Prevention of Future Deaths report
Page 2 · 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
Inadequate weekend mental health staffing and risk assessment for late prison transfers
Wider context from the report
“1. Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted. There are no mental health nurses available to assess/monitor prisoners over the weekend, thus making late transfers unsafe. The same concern applies, in principle, to public/bank holidays. There are different levels of healthcare at the weekends as compared to weekdays. This gives cause for concern given the inherent susceptibilities with which prisoners frequently present. Transfer itself creates vulnerability that requires additional support, intervention and care and is of particular concern where the transferring prisoner is being held in isolation within the Care and Separation Unit (CSU or ‘Seg’ as it is colloquially known). By virtue of the very different prison regime at the weekends (increased lock up periods/isolation in cells, fewer staff on duty, reduced activities) timely risk assessment is critical in the prevention of self-harm leading to death. Late transfer also risks inadequate assessment where the clinician concerned cannot access the prisoner’s full healthcare record, thus substantially reducing the amount of key information available to them. Where the transferring prisoner has not been seen by Healthcare, other clinicians such as mental health nurses cannot access the healthcare record database. There is no national guidance in relation to late transfers/cut-off points etc. 2. Commissioning of Mental Health/Healthcare Services: As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action. These issues are not unique to the Prison involved in Mr Brown’s case. ”
Source location
Mr Bradley Fraser Brown · 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
Instruct Governors not to enter local agreements accepting transferred prisoners on Fridays.

Verbatim wording from the response
“However, as a result of the concerns you have raised, the Governor at HMP Buckley Hall has instructed all Governors at the establishment that they should not enter into local agreements to accept transferred prisoners on a Friday. This will be reviewed once the changes to the provision of healthcare have been embedded. In addition, a range of measures has been implemented to ensure that all new arrivals receive the same level of care regardless of when they transfer takes place. First night procedures have been strengthened to ensure that all prisoners arriving at the prison are subject to a 72 hour period of monitoring, which includes randomly spaced welfare checks during lock up periods. A Challenge Support and Intervention Plan (CSIP) is opened for any new prisoners who have been subject to a period of segregation prior to transfer.”

Source location
2018-0374-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 10 May 2019
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
Strengthen first-night procedures by monitoring every new arrival for 72 hours, including random welfare checks during lock-up periods.

Verbatim wording from the response
“However, as a result of the concerns you have raised, the Governor at HMP Buckley Hall has instructed all Governors at the establishment that they should not enter into local agreements to accept transferred prisoners on a Friday. This will be reviewed once the changes to the provision of healthcare have been embedded. In addition, a range of measures has been implemented to ensure that all new arrivals receive the same level of care regardless of when they transfer takes place. First night procedures have been strengthened to ensure that all prisoners arriving at the prison are subject to a 72 hour period of monitoring, which includes randomly spaced welfare checks during lock up periods. A Challenge Support and Intervention Plan (CSIP) is opened for any new prisoners who have been subject to a period of segregation prior to transfer.”

Source location
2018-0374-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 10 May 2019
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
Open a Challenge Support and Intervention Plan for new prisoners segregated before transfer.

Verbatim wording from the response
“However, as a result of the concerns you have raised, the Governor at HMP Buckley Hall has instructed all Governors at the establishment that they should not enter into local agreements to accept transferred prisoners on a Friday. This will be reviewed once the changes to the provision of healthcare have been embedded. In addition, a range of measures has been implemented to ensure that all new arrivals receive the same level of care regardless of when they transfer takes place. First night procedures have been strengthened to ensure that all prisoners arriving at the prison are subject to a 72 hour period of monitoring, which includes randomly spaced welfare checks during lock up periods. A Challenge Support and Intervention Plan (CSIP) is opened for any new prisoners who have been subject to a period of segregation prior to transfer.”

Source location
2018-0374-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 10 May 2019
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
Require healthcare staff to notify the Orderly Officer when new arrivals miss appointments and record follow-up actions when prisoners refuse attendance.

Verbatim wording from the response
“This provides for a period of monitoring to ensure that vulnerability or violence is managed appropriately. Healthcare staff have also been instructed to notify the Orderly Officer if any prisoner misses an appointment in the early days, so that reasons for non-attendance can be followed up. If a prisoner refuses to attend, Healthcare will be informed and the actions taken recorded by prison staff.”

Source location
2018-0374-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 10 May 2019
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
Issue HMP Haverigg staff a reminder to confirm transfers with Healthcare so medical records are promptly reassigned and available on arrival.

Verbatim wording from the response
“Prior to any transfer there is a requirement for Healthcare staff at the sending establishment to assess each prisoner to ensure that any health concerns are recorded and communicated to the receiving prison and to confirm that the prisoner is medically fit to be moved. A notice has been issued to all staff at HMP Haverigg, which was the transferring prison in Mr Brown’s case, reminding them to confirm to Healthcare staff any transfer, so that medical records are reassigned promptly in order that they are immediately available when the prisoner arrives at the new establishment.”

Source location
2018-0374-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 10 May 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing weekday transfer schedules, advance warnings and exceptional weekend transfers are considered sufficient; removing Friday transfers would increase pressure and late arrivals.

Verbatim wording from the response
“are located in the appropriate category of prison. Inter prison transfers currently take place from Monday and Friday in accordance with a schedule agreed with the Prison Escort Court Service (PECS). Removing Friday from the schedule would put undue pressure on the remaining four days and increase the risk of late arrivals on those days. Prisons are always given advance warning of these scheduled transfers and PECS notify establishments of their anticipated arrival times, so that arrangements can be made. In terms of weekends, whilst there is provision at a national level for inter prison transfers to be facilitated on a Saturday or Sunday, this will only be done under exceptional circumstances and is extremely rare. Transfers generally only take place over a weekend when an emergency at one prison necessitates a move of prisoners to a different establishment.”

Source location
2018-0374-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 10 May 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NHS England is responsible for responding directly to concerns about healthcare processes and mental healthcare provision.

Verbatim wording from the response
“You have expressed concerns about the transfer of prisoners between prisons on a Friday and at weekends and how this may impact on the level of care and support available to them, particularly in respect of Healthcare and Mental Health assessments. I understand that NHS England will also be responding directly to your concerns in terms of their healthcare processes and will explain that the new specification for the provision of healthcare at Buckley Hall will include access to mental healthcare 7 days a week.”

Source location
2018-0374-Response-by-HM-Prison-and-Probation-Service
Page 1 · response
Published 10 May 2019
Open published response
30 Nov2018
Hertfordshire
Concerns raised1
1. Delays in transferring prisoners in acute mental health crisis to suitable secure hospitals
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 11
1. Action
  Conduct and maintain national annual audits benchmarking prisoner mental-health transfers and remissions.
  Stated by NHS EnglandStated completed
2. Action
  Use audit findings to identify delays, develop best practice and improve escalation processes, including through a standardised information template.
  Stated by NHS EnglandStated completed
3. Action
  Develop improved performance management and capability for the prisoner mental-health transfer pathway.
  Stated by NHS EnglandStated in progress
1. Action
  Identify and disseminate national good-practice examples and service expectations through a scheduled transfer and remission conference.
  Stated by NHS EnglandStated planned
2. Action
  Revise the Good Practice Guidance to clarify and standardise transfer and remission processes.
  Stated by NHS EnglandStated in progress
3. Action
  Submit the revised transfer and remission guidance for public consultation before national implementation.
  Stated by NHS EnglandStated planned
4. Action
  Conduct demand-and-capacity reviews and reconfigure adult low- and medium-secure services to improve geographical access, capacity and throughput.
  Stated by NHS EnglandStated in progress
5. Action
  Pilot specialist forensic community-care models and collaborative commissioning approaches to increase local ownership of the pathway.
  Stated by NHS EnglandStated in progress
6. Action
  Undertake a strategic demand-and-capacity review of adult high-secure services.
  Stated by NHS EnglandStated planned
7. Action
  Review the adult high-secure service specification through stakeholder co-design and co-production.
  Stated by NHS EnglandStated in progress
8. Action
  Implement nationally the revised integrated prison mental-health service specification, including seven-day provision, quality standards and local transfer-remission navigator functions.
  Stated by NHS EnglandStated in progress
Respondent positions 1
1. Position
  NHS England is responsible for commissioning prison healthcare and specialist secure mental health beds.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Thomas Nicol · 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

Thomas Nicol, a serving prisoner at HMP The Mount, was found hanging in his cell on 21 September 2015 and died in hospital on 25 September 2015. The report raised concern that the weeks-to-months taken to transfer prisoners in acute mental health crisis to suitable secure hospitals potentially puts lives at 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
Delays in transferring prisoners in acute mental health crisis to suitable secure hospitals
Wider context from the report
“That the length of time taken to transfer prisoners in acute mental health crisis to a suitable secure hospital potentially puts lives at risk ”
Source location
Thomas Nicol · 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
Conduct and maintain national annual audits benchmarking prisoner mental-health transfers and remissions.

Verbatim wording from the response
“1. An annual audit benchmarking data in relation to transfers and remissions;”

Source location
2018-0375-Response-by-NHS-England
Page 2 · response
Published 10 May 2019
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
Use audit findings to identify delays, develop best practice and improve escalation processes, including through a standardised information template.

Verbatim wording from the response
“These audits permit scrutiny on a national and local level and have helped to develop a better understanding of any obstacles leading to delays in the timely assessment and if appropriate, transfer and/or remission of prisoners to and from mental health in-patient services. This knowledge is being used to build on best practice and identify areas for further service development. For example, a previous audit led to the examination of the escalation process to be applied regionally and nationally to those persons for whom an assessment and / or referral remained outstanding. The audit indicated that gaps in the information required to facilitate the escalation of care incurred a delay in its processing. As a result, a template was developed confirming”

Source location
2018-0375-Response-by-NHS-England
Page 2 · response
Published 10 May 2019
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
Develop improved performance management and capability for the prisoner mental-health transfer pathway.

Verbatim wording from the response
“2. Improved performance management and capability;”

Source location
2018-0375-Response-by-NHS-England
Page 2 · response
Published 10 May 2019
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
Identify and disseminate national good-practice examples and service expectations through a scheduled transfer and remission conference.

Verbatim wording from the response
“In addition, improved performance management and capability is being developed in this area. Good practice examples relating to the pathway in some parts of the country within prison and respective mental health in-patient services are being identified and processes to disseminate and share this information nationally is a specific focus. For example, a national transfer and remission best practice conference is scheduled to take place on 19 March 2019 which will allow NHS England to present its findings and service expectations to local commissioners and providers alike, particularly in relation to escalation processes. In addition, responsibility for reviewing the Good Practice Guidance 2011 has been passed to NHS England, which is revising this document in order to clarify and standardise the transfer process.”

Source location
2018-0375-Response-by-NHS-England
Page 3 · response
Published 10 May 2019
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
Revise the Good Practice Guidance to clarify and standardise transfer and remission processes.

Verbatim wording from the response
“In addition, improved performance management and capability is being developed in this area. Good practice examples relating to the pathway in some parts of the country within prison and respective mental health in-patient services are being identified and processes to disseminate and share this information nationally is a specific focus. For example, a national transfer and remission best practice conference is scheduled to take place on 19 March 2019 which will allow NHS England to present its findings and service expectations to local commissioners and providers alike, particularly in relation to escalation processes. In addition, responsibility for reviewing the Good Practice Guidance 2011 has been passed to NHS England, which is revising this document in order to clarify and standardise the transfer process.”

Source location
2018-0375-Response-by-NHS-England
Page 3 · response
Published 10 May 2019
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
Submit the revised transfer and remission guidance for public consultation before national implementation.

Verbatim wording from the response
“The proposed guidance will be submitted for public consultation prior to implementation nationally.”

Source location
2018-0375-Response-by-NHS-England
Page 3 · response
Published 10 May 2019
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 demand-and-capacity reviews and reconfigure adult low- and medium-secure services to improve geographical access, capacity and throughput.

Verbatim wording from the response
“3. Demand and capacity service reviews in relation to adult low and medium secure services, an initiative to increase local ownership of the pathway through collaborative commissioning and the development of new forensic community models of care;”

Source location
2018-0375-Response-by-NHS-England
Page 2 · response
Published 10 May 2019
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
Pilot specialist forensic community-care models and collaborative commissioning approaches to increase local ownership of the pathway.

Verbatim wording from the response
“3. Demand and capacity service reviews in relation to adult low and medium secure services, an initiative to increase local ownership of the pathway through collaborative commissioning and the development of new forensic community models of care;”

Source location
2018-0375-Response-by-NHS-England
Page 2 · response
Published 10 May 2019
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
Undertake a strategic demand-and-capacity review of adult high-secure services.

Verbatim wording from the response
“4. Demand and capacity service reviews in relation to adult high secure services;”

Source location
2018-0375-Response-by-NHS-England
Page 2 · response
Published 10 May 2019
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
Review the adult high-secure service specification through stakeholder co-design and co-production.

Verbatim wording from the response
“In relation to high secure services, a similar demand and capacity review will be undertaken as part of strategic commissioning work and the current specification is being reviewed via the established NHS England processes of co-design and co-production. This review is in its early stages and NHS England aims to publish the results of this review during 2019/20.”

Source location
2018-0375-Response-by-NHS-England
Page 3 · response
Published 10 May 2019
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
Implement nationally the revised integrated prison mental-health service specification, including seven-day provision, quality standards and local transfer-remission navigator functions.

Verbatim wording from the response
“In March 2018 NHS England published a new integrated prison mental health service specification which significantly revised the previous specifications. It included provision for more flexible mental health services with seven days a week provision to ensure that those in mental health care are able to access the appropriate support even at the weekends. It also, for the first time, included the Royal College of Psychiatrists Quality Network for Prison Mental Health Services (QNMHPS) standard for mental health care in prisons. These standards were written with mental health”

Source location
2018-0375-Response-by-NHS-England
Page 3 · response
Published 10 May 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NHS England is responsible for commissioning prison healthcare and specialist secure mental health beds.

Verbatim wording from the response
“Alongside the Department, you issued your report to the Ministry of Justice and NHS England. I am advised that NHS England has responded in detail to your concerns. As you will know, NHS England is responsible for the commissioning of prison health care services and the commissioning of specialist mental health services, including secure adult mental health beds.”

Source location
2018-0375-Response-by-Department-of-Health-Social-Care
Page 1 · response
Published 10 May 2019
Open published response
11 Oct2017
Bedfordshire and Luton
Concerns raised1
1. Lack of Wing Transfer documentation conveying past ACCTs and risk factors
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Issue Bedford guidance requiring staff to share prisoner risk information during location changes verbally, on NOMIS and in wing observation books, with monthly recording checks.
  Stated by HM Prison and Probation ServiceStated completed
Respondent positions 1
1. Position
  Existing policy requires recording and sharing prisoner risks and needs before location changes through wing books, NOMIS and verbal communication.
  Stated by HM Prison and Probation ServiceExisting arrangements considered sufficient
AI-generated summary

Mark Daniel VAGNONI · 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

Mark Daniel Vagnoni, who had paranoid schizophrenia and was on remand at HM Prison Bedford, was found hanging in his cell on 11 July 2016 and died two days later. Concerns included the arrangements for risk assessment and observation after an ACCT was opened, the accessibility of information about previous ACCTs in NOMIS, and the lack of Wing Transfer documentation containing relevant risk information.

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 Wing Transfer documentation conveying past ACCTs and risk factors
Wider context from the report
“3. The jury were also concerned that there appears to be no Wing Transfer documentation, which could have included information about past ACCTs and indeed past risk factors. ”
Source location
Mark Daniel VAGNONI · 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
Issue Bedford guidance requiring staff to share prisoner risk information during location changes verbally, on NOMIS and in wing observation books, with monthly recording checks.

Verbatim wording from the response
“In October 2017 all staff at HMP Bedford were reminded through a Notice to Staff of the importance of ensuring that all available information, including any identified risk factors, must be considered prior to changing a prisoner’s location, and shared with staff responsible for their care at the receiving location. Information must be shared both verbally and on NOMIS, with entries also made in the wing observation book. Residential managers are required to undertake monthly checks on wing observation books and NOMIS to ensure that information is being recorded accurately and comprehensively.”

Source location
2017-0286-Response-by-HM-Prison-Probation-Service
Page 3 · response
Published 27 November 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
Existing policy requires recording and sharing prisoner risks and needs before location changes through wing books, NOMIS and verbal communication.

Verbatim wording from the response
“As you may be aware, PS1 75/2011 Residential Services requires that any information regarding the needs, risks or behaviours of prisoners who are showing signs of distress or self-harm must be properly recorded in the wing occurrence book or equivalent, and shared appropriately with other teams.”

Source location
2017-0286-Response-by-HM-Prison-Probation-Service
Page 3 · response
Published 27 November 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Premature closure of ACCTs for newly transferred prisoners before sufficient review, assessment and communication

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to hold an ACCT Case Review immediately before transfer

Concerns raised5

Failure to record transfer decisions and pre-transfer checks

Failure to assess risk before prisoner transfer

Failure to interview transferred prisoners and provide distraction materials on reception

Failure to provide receiving wings with relevant prisoner risk information during transfer handover

Failure to assess risk on reception and after transfer

Concerns raised5

Inappropriate minimisation of prisoners’ illness or vulnerability during transfer decisions

Failure to provide coordinated interpreted communication about prisoner transfers

Failure of staff to understand transfer rationale and destination suitability

Failure to ensure prisoners understand transfer reasons and destination regimes

Failure of receiving-wing staff to attend final ACCT case reviews before transfer

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to search prisoners before transport

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to review information about prisoners entering the prison

Actions described in response 2

Respondent positions 3

Actions described in response 3

Respondent positions 1

Actions described in response 2