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

Distinct published reports

Individual concerns
43

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
62

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation 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.

  1. South Yorkshire (Eastern)

    AI-generated summary

    Anthony Benjamin Patrick Fraser · 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 Benjamin Patrick Fraser had terminal multiple myeloma and died at Doncaster Royal Infirmary on 24 September 2015 after his condition significantly progressed and palliative care was initiated. The report identified the absence of a robust system for conveying summary medical information to receiving A&E departments when inmates are transferred with an acute illness, which could delay diagnosis for other inmates.

    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

    Absence of a robust system for conveying summary medical information to receiving A&E departments during acute illness transfers

    Wider context from the report

    “I heard evidence that the medical records on the electronic Spine One contain a summary overview of a person’s medical status which should be sent to A&E Departments where patients have been referred. This information is readily accessible but in Mr Fraser’s case when he was referred to A&E on 15th August 2015, this information was not conveyed by them to the receiving hospital. I also heard in evidence that there is no system for ensuring that such information is sent and therefore is “hit and miss” as to whether or not it is sent. Whilst I concluded that in Mr Fraser’s case this did not affect the ultimate outcome due to him re-attending four days later and given the very aggressive nature of the cancer from which he was suffering, it is clear that for other inmates with different conditions, failure to provide such information may well delay diagnosis or make it extremely difficult to reach diagnosis. Accordingly consideration needs to be given to implementing a system where such information is conveyed for every such inmate in a timely fashion. Summary of concerns:- 1. Absence of a robust system for conveying summary medical information to receiving A&E departments when inmates are transferred with an acute illness. . ”

    Source location

    Anthony Benjamin Patrick Fraser · 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

    Implement a jointly authored procedure defining custodial and healthcare responsibilities for conveying summary medical information to receiving A&E departments.

    Verbatim wording from the response

    “Following the receipt of the Regulation 28 Report, a collaborative meeting took place with the Governor of HMP Lindholme, ████████ and the Associate Director for Offender Health, ████████ and the Head of Healthcare at HMP Lindholme, ████████ and the Head of Security at HMP Lindholme, ████████. The purpose of the meeting was to develop a shared system to address the concerns you have raised in the Preventing Future Deaths report.”

    Source location

    2016-0225-Response-by-Nottinghamshire-Healthcare-NHS-Trust
    Page 2 · response
    Published 8 June 2016

    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 compliance review of the information-transfer procedure to confirm full implementation of the system.

    Verbatim wording from the response

    “A procedure was co-authored by the group, clearly identifying the roles and responsibilities of both Custodial and Healthcare staff. A copy of the procedure has been included with this letter. The procedure has been issued to staff and is now in operation. A review of compliance will be undertaken by the Head of Healthcare within the coming month, to ensure we have achieved full implementation for a robust system of conveying summary medical information to A&E depts.”

    Source location

    2016-0225-Response-by-Nottinghamshire-Healthcare-NHS-Trust
    Page 2 · response
    Published 8 June 2016

    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 the information-transfer procedure at the Offender Health Learning the Lessons Forum to support adoption by other establishments.

    Verbatim wording from the response

    “A copy of the procedure will be shared at the Offender Health Learning the Lessons Forum on the 9th of September 2016, to ensure colleagues in other establishments also have a system in place for the transfer of medical information, thereby avoiding future deaths.”

    Source location

    2016-0225-Response-by-Nottinghamshire-Healthcare-NHS-Trust
    Page 2 · response
    Published 8 June 2016

    Open published response

  2. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    David James Hallet · 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

    David James Hallet was serving a prison sentence when he was transferred to HMP Rye Hill, admitted to hospital and diagnosed with metastatic pancreatic cancer. He later died at HMP Parc after being transferred to its palliative care suite; concerns included inadequate healthcare at HMP Rye Hill, linked in the report to insufficient preparation and resources for a national prison re-roll.

    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

    Inability of prison staff to cope with transferred prisoner populations

    Wider context from the report

    “• The evidence indicated that one of the primary reasons for this was lack of preparation by the Prison Authorities staff and an inability to cope with the types of prisoners who were transferred to HMP Rye Hill. The clinical review undertaken by Healthcare Inspectorate Wales was critical of the care he received at HMP Rye Hill and the evidence clearly indicated that a lack of preparation for the re-roll and the lack of adequate resources were the primary reason for this substandard care. • Whilst it is appreciated that HMP Rye Hill may not be subject to a further re-roll it is of concern that other re-rolls nationally may be being considered and which may conceivably give rise to issues similar to those presented in this case. ”

    Source location

    David James Hallet · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. South Yorkshire (Western)

    AI-generated summary

    Neil Budziszewski · 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

    Neil Budziszewski was arrested for theft while intoxicated and detained overnight at Ecclesfield Police Station after being charged. He was found dead in his cell before being transferred to court. The report identified numerous failures involving risk assessment, communication and handovers, monitoring, recording, and obtaining medical assessment, including failures to recognise and respond to the risks of acute alcohol withdrawal syndrome.

    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 transferred risk-assessment information

    Wider context from the report

    “(5) When Mr Budziszewski was returned to Ecclesfield Police Station, the afternoon custody sergeant failed to complete his own risk assessment query issues arising from the risk assessment undertaken at Bridge Street. It is likely that the escorting officers could have added a great deal of knowledge for the custody sergeant about what had been said by Mr Budziszewski at Bridge Street. ”

    Source location

    Neil Budziszewski · 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 complete Prison Escort Forms for detainee transfers

    Wider context from the report

    “(2) The afternoon custody sergeant failed to complete a Prison Escort Form for a transfer to Bridge Street (for LiveScan identification) in breach of guidance. Similarly, whilst the receiving custody sergeant at Bridge Street commenced a custody record and completed a risk assessment, he also failed to complete a Prison Escort Form for the transfer back. ”

    Source location

    Neil Budziszewski · 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

    Document and standardise custody handover requirements, including transfer of risk-assessment information.

    Verbatim wording from the response

    “The process for handovers is now documented and is consistent across the force. The process is that the sergeant handing over will summarise to the incoming sergeant personal information about the detainee, details of the offence and the stage of the investigation and any specific risk factors. The focus of the handover is to be around the risk assessment which has been completed. Appendix C shows a completed copy of the handover Sergeants are expected to complete. As this is a live copy, third party data has been redacted out to ensure compliance with the Data Protection Act.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 5 · response
    Published 23 March 2015

    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 Prisoner Escort Form policy and inform custody staff that forms are required for all detainee transfers.

    Verbatim wording from the response

    “It would appear that this was a commonly misunderstood form across South Yorkshire Police with custody staff believing that the PER form was only required where a detainee was being transferred to the custody of another agency and not internally. Following the outcome of the inquest touching upon the death of Mr Neil Budziszewski the policy has been reviewed and all custody staff have been informed of the requirement for this form to be completed when transferring a prisoner between custody suites or police stations as well as when transferring to an external agency. This will be followed up with a written notification to all custody staff explaining the need for this form to be completed whenever a detainee is moved from custody regardless of the agency transferring the detainee.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 1 · response
    Published 23 March 2015

    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

    Circulate written notification explaining that Prisoner Escort Forms must be completed whenever detainees move from custody.

    Verbatim wording from the response

    “It would appear that this was a commonly misunderstood form across South Yorkshire Police with custody staff believing that the PER form was only required where a detainee was being transferred to the custody of another agency and not internally. Following the outcome of the inquest touching upon the death of Mr Neil Budziszewski the policy has been reviewed and all custody staff have been informed of the requirement for this form to be completed when transferring a prisoner between custody suites or police stations as well as when transferring to an external agency. This will be followed up with a written notification to all custody staff explaining the need for this form to be completed whenever a detainee is moved from custody regardless of the agency transferring the detainee.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 1 · response
    Published 23 March 2015

    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

    Retrain custody Inspectors and reiterate Prisoner Escort Form completion requirements and required transfer details to custody staff.

    Verbatim wording from the response

    “As referred to in paragraph two, there appear to have been a number of misunderstandings around the Prisoner Escort Form. These errors have now been retrained to custody Inspectors and will be reiterated to custody staff and the details to be included by 31 May 2015.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 7 · response
    Published 23 March 2015

    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 custody training and practices comply with Home Office standards; the identified failures were attributed to individual officer error rather than deficient arrangements.

    Verbatim wording from the response

    “Whilst Mr Budziszewski was at Bridge Street custody he was not cooperative with the risk assessment process. In any event this should have been reviewed upon his return to Ecclesfield. Custody staff are aware of the importance of the risk assessment and the requirement to regularly review where information is missing and therefore this failure on this occasion is down to officer error and not due to an issue with the training and practices. Appendix A refers to the new risk assessment which has been in force since October 2014.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 2 · response
    Published 23 March 2015

    Open published response

  4. Mid Kent and Medway

    AI-generated summary

    Alex 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

    Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.

    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 understand YOT authority to initiate secure-estate transfers

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”

    Source location

    Alex Kelly · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver custody-transfer training to relevant staff and produce and cascade supporting flowcharts and guidance notes.

    Verbatim wording from the response

    “Point 2,c; In conjunction with 2,b, training will be delivered to all case holding practitioners and all other members of YOT staff who may have contact with a young person in custody to ensure they fully understand the arrangements in place to request a move from one custodial establishment to another. A flow chart and guidance notes will be produced and cascaded to all practitioners. This training and documentation will be completed by April 2015. Documentation will be available to the Coroner, if so required upon completion.”

    Source location

    2014-0555-Response-by-Medway-Youth-Offending-Service
    Page 3 · response
    Published 28 December 2014

    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

    Provide case workers with accommodation and transfer guidance and require placement suitability to be considered at remand and sentence-planning meetings and reviews.

    Verbatim wording from the response

    “The Case Workers have now received guidance from the YJB in relation to the types of accommodation available and new referral process to transfer a young person if needed. At all Remand and Sentence planning meetings/reviews attendees discuss whether Cookham Wood and/or the equivalent establishment is the appropriate placement for the young person as requested by the Placement Review and Transfer Protocol, YJB Placement Service (June 2013). This new policy lays down the process by which a transfer request may be made. However, the final decision sits with the YJB placements Team.”

    Source location

    2014-0555-Response-by-Medway-Youth-Offending-Service
    Page 5 · response
    Published 28 December 2014

    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 Youth Justice Board placements team has final authority to decide requests to transfer a young person between custodial establishments.

    Verbatim wording from the response

    “The Case Workers have now received guidance from the YJB in relation to the types of accommodation available and new referral process to transfer a young person if needed. At all Remand and Sentence planning meetings/reviews attendees discuss whether Cookham Wood and/or the equivalent establishment is the appropriate placement for the young person as requested by the Placement Review and Transfer Protocol, YJB Placement Service (June 2013). This new policy lays down the process by which a transfer request may be made. However, the final decision sits with the YJB placements Team.”

    Source location

    2014-0555-Response-by-Medway-Youth-Offending-Service
    Page 5 · response
    Published 28 December 2014

    Open published response

  5. County Durham and Darlington

    AI-generated summary

    Zeeyad Hamadi · 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

    Zeeyad Hamadi was a prisoner at HMP Frankland who became unwell, was diagnosed with Hodgkins Lymphoma, and deteriorated while arrangements were made to transfer him to a London hospital for private chemotherapy. Concerns included inadequate weighing and medical record keeping, limited communication between prison and hospital staff, unclear funding and transfer arrangements, and the absence of a system or responsible point of contact to manage the transfer, contributing to delay.

    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 policy or guidance for prison staff and health care providers managing complex privately funded transfers

    Wider context from the report

    “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented. Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS. ”

    Source location

    Zeeyad Hamadi · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester South

    AI-generated summary

    Billy Paul Thomas Salton · 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

    Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort 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

    Failure to complete prisoner transfer documentation accurately

    Wider context from the report

    “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy. 2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is. 3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record. 4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted. 5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters. 6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate. 7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen. 1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy). 2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody. 3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked. 4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded. 1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody. 2. Staff should be reminded that all cell checks should be accurately documented. 3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY. ”

    Source location

    Billy Paul Thomas Salton · 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

    Issue and check improved guidance for sergeants on completing, timing and signing off Prisoner Escort forms.

    Verbatim wording from the response

    “Since your observations we have put out improved guidance on completion of the PER form to sergeants which include what to record, when it is to be done and how it is to be signed off. This has been extensively checked and has led to improvements in standards.”

    Source location

    2014-0002-Response-by-Greater-Manchester-Police
    Page 3 · response
    Published 6 January 2014

    Open published response
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Data last updated 7 September 2026