7 Apr 2026 Mark Robert Smith · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Unavailability of larger disabled cells adapted for constant watch View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mark Robert Smith · 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 Robert Smith, who was detained at HMP Thameside, died after an epileptic seizure led to cardiac arrest. The report describes concerns about medication prescribing and administration, hospital-to-prison discharge and communication, access to his cell, observation arrangements and records, staffing, and the lack of equipment for resuscitation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of larger disabled cells adapted for constant watch
Wider context from the report “(4) There are no larger disabled cells (which can accommodate hospital beds and wheelchairs) adapted to also facilitate a constant watch. Security concerns, in this might not be possible, and a similar situation might occur to that in Mark’s case. (HMPPS)
” Source location Mark Robert Smith · Prevention of Future Deaths report
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25 Oct 2024 Mark Stephen Beresford · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure to consult a supervising officer on ACCT observation levels View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
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AI-generated summary
Mark Stephen Beresford · 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 Stephen Beresford died at Bassetlaw District General Hospital on 7 July 2023 after applying a ligature while detained at HMP Ranby, having been discovered unresponsive and resuscitated. The jury found that he was suffering significant mental ill health and identified failings in the assessment and management of his mental health and self-harm risk, ACCT observations, completion of an action plan, response to his cell bell, and staffing. The report also raises concerns about prison leadership’s understanding and assessment of risk and its lack of candour and reflection during the inquest.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consult a supervising officer on ACCT observation levels
Wider context from the report “I heard evidence that the prison authorities have already taken important steps, which I am satisfied address many of the concerns arising from Mark’s death. I am concerned however, that despite very strong evidence to the contrary, they maintained the risk assessments conducted on 2 and 3 July were reasonable in all the circumstances.
The supervising officer involved in the decision to close Mark’s ACCT on the morning of 3 July 2023, gave evidence that there was no likelihood Mark would commit further ACCTs of self-harm. While the inexperienced officer who later reopened the ACCT set Mark’s observations at one no more than two hours apart, relying in part on the fact that is what they had been set at when the ACCT had been reopened the previous day. However, there had since been two significant risk incidents and the officer did not consult a supervising officer as required by PSI 64/2011 . It is difficult to understand the prison’s position that these assessments were reasonable in all the circumstances.
Furthermore, on two occasions, the Head of Operations gave evidence that was incorrect and liable to mislead the jury and/or the coroner.
He gave evidence confirming the requirement for a person raising a concern under the ACCT process to consult with a supervising officer in respect of observation levels. He then added:
“I firmly believe that the supervising officers who gave evidence earlier this week, whether they recall it or not, would naturally have had that conversation, out of being inquisitive, that would be my own personal view point but in terms of the prison stance, that’s what the policy says.”
When it was pointed out to him that that was not supported by either of the witnesses involved – who were both very clear that there had been no consultation - he apologised and suggested he had misunderstood.
I am troubled by the fact that the Head of Operations, instead of reflecting on the significance of that evidence in terms of learning lessons from Mark’s death, suggested to the jury that these witnesses must have been mistaken.
The second occasion concerned the issue of cell bell cover on the day of the event that caused Mark’s death.
Mark was housed on HB3 North. The Head of Operations gave evidence that it is normal for both HB3 North and HB3 South to have a single officer detailed to deal with cell bells over the lunch period. The officer on duty on 3 July was however very clear in his evidence that he was detailed to cover HB3S only. Every other prison witness asked about this agreed that there should be an officer covering each side of HB3 over lunch.
Curious and concerned as to how a member of the prison’s leadership team could have made such an error, I later recalled and asked the Head of Operations for an explanation. He could provide none. Although, he did later apologise for his difficulty answering other questions asked of him, explaining that he does not usually work in safer custody.
1. That, notwithstanding steps since taken to improve work around ACCT processes and risk assessments, there remains an issue with understanding and assessing risk, which extends up to the leadership team at HMP Ranby.
2. That there was a failure by the prison authorities to act with due reflection and candour during the inquest which, if unaddressed, will impede their ability to fully learn the lessons from deaths in custody.
” Source location Mark Stephen Beresford · Prevention of Future Deaths report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for delivering suicide and self-harm risk management and the ACCT process at HMP Ranby sits with the Head of Safety.
Verbatim wording from the response “As you will also be aware responsibility for the delivery of the management of those prisoners at risk of suicide and self-harm and the effective management of the ACCT process at HMP Ranby sits with the Head of Safety.” Source location Response from HMPPS
Open published response
Concerns raised 2
Lack of audit trail for signed constant observation forms and sergeant briefings View source Lack of timely controlled handover of constant observation forms View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
South Yorkshire Police
Conduct compliance dip sampling, including CCTV checks, to verify constant-observation briefings and supervisory checks.
View source
South Yorkshire Police
Consult the Performance and Governance team about activating body-worn video during constant observations.
View source
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AI-generated summary
Matthew Terrill · 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
Matthew Terrill was taken into police custody on 22 April 2020 while intoxicated by multiple drugs and exhibiting behaviour associated with drug intoxication and possibly acute mental health symptoms. He was placed on level 4 constant observations, during which officers with limited experience and no briefing observed him until he was found not breathing. The substantive concerns included inadequate police training on drug intoxication, mental health symptoms, positional asphyxia, constant observations and custody handovers, as well as weaknesses in documentation and supervision processes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of audit trail for signed constant observation forms and sergeant briefings
Wider context from the report “6. Lack of safety net for custody suit documentation, specifically the constant supervision forms.
I am told that whilst there has been a welcomed change to the format of the constant observation forms, there is no safety net for ensuring that these forms are handed over in a timely manner or by the custody sergeant. I am also told that there is no audit trail in place for checking that these forms are being signed by police or custody officers to ensure that the envisaged sergeant briefing is being given . I am concerned that there is a risk of future death to detained persons on level 4 constant supervision in circumstances where the sitting officers may not be experienced in the task, have not been trained, and are not consistently being briefed by the custody officers.
” Source location Matthew Terrill · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of timely controlled handover of constant observation forms
Wider context from the report “6. Lack of safety net for custody suit documentation, specifically the constant supervision forms.
I am told that whilst there has been a welcomed change to the format of the constant observation forms, there is no safety net for ensuring that these forms are handed over in a timely manner or by the custody sergeant . I am also told that there is no audit trail in place for checking that these forms are being signed by police or custody officers to ensure that the envisaged sergeant briefing is being given. I am concerned that there is a risk of future death to detained persons on level 4 constant supervision in circumstances where the sitting officers may not be experienced in the task, have not been trained, and are not consistently being briefed by the custody officers.
” Source location Matthew Terrill · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct compliance dip sampling, including CCTV checks, to verify constant-observation briefings and supervisory checks.
Verbatim wording from the response “Training/ CPD will be given to all Custody Sergeants following this review setting out clear standards and expectations around their role and responsibilities of this document. Dip samples will be carried out by the Custody Inspectors to ensure compliance, this will include reviewing of CCTV to ensure that this document is briefed, relevant checks by the Sergeant are carried out for anyone under constant observations.” Source location Response from South Yorkshire Police and Humberside Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult the Performance and Governance team about activating body-worn video during constant observations.
Verbatim wording from the response “The Custody lead for South Yorkshire Police is to have further consultation with the Performance and Governance team to look at whether BWV should be activated when observing a prisoner, this could then capture the briefing, roles and responsibilities, action of the officers and any behaviour of the detainee.” Source location Response from South Yorkshire Police and Humberside Police
Open published response
Concerns raised 1
Failure to ensure correct levels of observation up to constant watch View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Martin Samuel WILLIS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Martin Samuel Willis was a serving prisoner at HMP Stoke Heath when he was found hanging in his cell on 15 September 2022. He was on the suicide and self-harm prevention scheme, but concerns included failures in observation recording and supervision, uncertainty about the appropriate observation level and possible transfer for mental health treatment, and the need for a collective review of the care provided.
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× 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 correct levels of observation up to constant watch
Wider context from the report “3. Overriding issues remain as to whether or not the late Mr Willis was on the correct levels of observation up to constant watch and whether he should have been transferred to an psychiatric grounds for treatment at another prison establishment with a hospital wing.
” Source location Martin Samuel WILLIS · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider constant supervision when ligature material has been removed.
Verbatim wording from the response “• Removal of any ligature material suggests that the prisoner is an immediate threat to themselves and therefore constant supervision will be considered.” Source location 2024-0171 - Response from HMPPS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind Case Co-Ordinators to record reasons when a discussed constant watch is deemed inappropriate.
Verbatim wording from the response “• Case Co-ordinators have been reminded that if a constant watch is discussed and deemed not appropriate then this should be recorded with an acceptable reason.” Source location 2024-0171 - Response from HMPPS
Open published response
21 Mar 2019 John Wright · Prevention of Future Deaths report Oxfordshire
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Concerns raised 1
Lack of guidance for reducing observations of newly arrived prisoners from constant watch View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care UK HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Care UK
Train staff to comply with PSI 64/2011 requirements for managing prisoners at risk of harm.
View source
Care UK
Consolidate self-harm and suicide-risk training through the PROTECT initiative, including comprehensive patient assessment and proactive ACCT involvement.
View source
Care UK
Provide internationally accredited ASIST training to all patient-facing staff to improve identification and management of suicide risk.
View source
HM Prison and Probation Service
Issue a national learning bulletin guiding prisons on setting observation levels for prisoners at risk.
View source
HM Prison and Probation Service
Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.
View source
HM Prison and Probation Service
Open an ACCT and require multidisciplinary review before reducing observations, recording decisions in the ACCT document.
View source
HM Prison and Probation Service
Brief duty governors that observation decisions must be risk-based and unaffected by resource constraints, with continuing reminders.
View source See 4 more actions
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AI-generated summary
John Wright · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Wright, aged 32, died at Bullingdon Prison on 15 December 2017 after being found partially suspended by an electrical cable in his cell. He had expressed suicidal thoughts and had previously been kept on constant watch, but observations were reduced to twice hourly during reception. The concerns relate to the receipt and sharing of information about heightened suicide risk and the guidance and decision-making processes for reducing observation levels.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of guidance for reducing observations of newly arrived prisoners from constant watch
Wider context from the report “The second matter I wish to raise, also to the prison and healthcare, is in relation to the level of observations. I heard evidence that this is often a joint responsibility held by the prison and healthcare. In this case, Mr Wright had been on constant watch, but a decision was taken during the reception process to step down to twice hourly observations. Given that staff may not have access to all available information in those first few hours, and the fact that there will not have been an opportunity for a prisoner to be observed over a significant period of time, and the fact that a more detailed assessment will not have taken place yet, there should in my view be some guidance to staff when reducing observations from constant watch .
I note that the Prison and Probation Ombudsman stated at the beginning of her report that ……. ‘Mr Wright had been under constant watch by police and court staff because he said he wanted to take his life at the earliest opportunity. Although prison staff started suicide and self-harm prevention procedures when Mr Wright arrived at Bullingdon, they reduced the level of observations from constant to twice an hour. In my view, this decision was misjudged and taken far too quickly, without a proper assessment of Mr Wright’s risk.’
I appreciate there is a great deal of responsibility on prison and healthcare staff when making assessments. Much depends on how they assess the prisoner in front of them. It may be appropriate to reduce a newly arrived prisoner from constant cell watch to less frequent observations on occasions. The concern which I raise relates to such decisions being made in reception and I enquire if there should be some guidance available to assist staff in their decision-making process? For example, should such a decision be postponed until a further assessment has been carried out the following day?
I realise that this issue is not straightforward and there are significant resource implications in keeping a prisoner under constant watch.
” Source location John Wright · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train staff to comply with PSI 64/2011 requirements for managing prisoners at risk of harm.
Verbatim wording from the response “All staff are trained to adhere to the requirements of PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others. The PSI specifies that staff should be trained at least every three years. In addition, Care UK have substantially consolidated this training with it’s PROTECT initiative which upholds standards to protect patients and maintain safety, including thoroughly assessing all patients and proactive involvement with the ACCT process. A copy of the PROTECT initiative is attached.” Source location 2019-0175-Response-by-CARE-UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consolidate self-harm and suicide-risk training through the PROTECT initiative, including comprehensive patient assessment and proactive ACCT involvement.
Verbatim wording from the response “All staff are trained to adhere to the requirements of PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others. The PSI specifies that staff should be trained at least every three years. In addition, Care UK have substantially consolidated this training with it’s PROTECT initiative which upholds standards to protect patients and maintain safety, including thoroughly assessing all patients and proactive involvement with the ACCT process. A copy of the PROTECT initiative is attached.” Source location 2019-0175-Response-by-CARE-UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide internationally accredited ASIST training to all patient-facing staff to improve identification and management of suicide risk.
Verbatim wording from the response “Staff meetings are held every two weeks to continue to improve and share knowledge and lessons learned regarding the management of prisoners in custody. Currently HMPPS are providing specialist HMPPS training for both healthcare and discipline staff; “Understanding Risk: Why is Risk Risky?” and “Defensible Decision Making”, both of which seek to reinforce rational and appropriate decisions when applying the ACCT process and understanding suicide risk. Care UK are providing ASIST - Applied Suicide Intervention Skills Training, which is an internationally accredited and licensed 2-day course to all patient-facing staff to increase their confidence in identifying suicide risk. This improved learning, supported by SASH training will better inform decision making in all cases, including those cases where removal from constant watch is being considered.” Source location 2019-0175-Response-by-CARE-UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a national learning bulletin guiding prisons on setting observation levels for prisoners at risk.
Verbatim wording from the response “With regard to your second concern, setting the appropriate level of observations for a prisoner who has been identified as being at risk is a difficult decision, and we have recently issued a learning bulletin to all prisons providing guidance about the issues to consider when making it. At HMP Bullingdon, the Governor has reminded the escort contractors of the importance of alerting reception staff in all cases in which constant supervision has been in place prior to a prisoner’s arrival. In all such cases the process is that the duty governor is informed and all documentation is studied to establish definitively the level of observations to which the prisoner has been subject, in order to avoid confusion over different organisational terminology.” Source location 2019-0175-Response-by-HM-Prison-Probation-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.
Verbatim wording from the response “With regard to your second concern, setting the appropriate level of observations for a prisoner who has been identified as being at risk is a difficult decision, and we have recently issued a learning bulletin to all prisons providing guidance about the issues to consider when making it. At HMP Bullingdon, the Governor has reminded the escort contractors of the importance of alerting reception staff in all cases in which constant supervision has been in place prior to a prisoner’s arrival. In all such cases the process is that the duty governor is informed and all documentation is studied to establish definitively the level of observations to which the prisoner has been subject, in order to avoid confusion over different organisational terminology.” Source location 2019-0175-Response-by-HM-Prison-Probation-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Open an ACCT and require multidisciplinary review before reducing observations, recording decisions in the ACCT document.
Verbatim wording from the response “In all cases in which constant supervision has been in place, an Assessment, Care in Custody and Teamwork (ACCT) is opened and any decision to reduce the level of observations will be taken at a multidisciplinary case review (including the Duty Governor, a nurse and a member of prison staff, as well as the prisoner) and recorded in the ACCT document. All duty governors have been briefed and will frequently be reminded that decisions about the use of constant supervision should be based on the level of risk and must not be affected by resource constraints.” Source location 2019-0175-Response-by-HM-Prison-Probation-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Brief duty governors that observation decisions must be risk-based and unaffected by resource constraints, with continuing reminders.
Verbatim wording from the response “In all cases in which constant supervision has been in place, an Assessment, Care in Custody and Teamwork (ACCT) is opened and any decision to reduce the level of observations will be taken at a multidisciplinary case review (including the Duty Governor, a nurse and a member of prison staff, as well as the prisoner) and recorded in the ACCT document. All duty governors have been briefed and will frequently be reminded that decisions about the use of constant supervision should be based on the level of risk and must not be affected by resource constraints.” Source location 2019-0175-Response-by-HM-Prison-Probation-Service
Open published response
Concerns raised 3
Lack of verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels View source Insufficient training emphasis on correct observation levels View source Failure to specify detainee observation levels precisely View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
College of Policing DCC Nick Ephgrave G4S Care And Justice Services (UK) Limited Staffordshire Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Staffordshire Police
Issue guidance requiring medical practitioners to provide custody sergeants with verbal consultation updates.
View source
Staffordshire Police
Review Force Policy to incorporate the verbal medical consultation update requirement.
View source
College of Policing and DCC Nick Ephgrave
Review Detention and Custody Authorised Professional Practice to consider guidance on medical practitioner–custody sergeant consultation, observation levels and detailed medical records.
View source
Staffordshire Police
Consider further training to supplement and enhance observation-level guidance.
View source
G4S Care And Justice Services (UK) Limited
Provide mandatory custody-officer training on setting observation levels during induction, aligned with current custody guidance.
View source
College of Policing and DCC Nick Ephgrave
Maintain training standards that emphasise selecting correct detainee observation levels and direct users to Authorised Professional Practice.
View source
Staffordshire Police
Instruct custody officers and medical practitioners to record agreed observation levels and avoid non-specific continuation phrases.
View source
College of Policing and DCC Nick Ephgrave
Add advice to Detention and Custody Authorised Professional Practice requiring doctors and custody sergeants to specify observation levels precisely.
View source See 5 more actions
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AI-generated summary
Name not published · 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
The deceased was arrested on 2 October 2011 and held in custody, where he received prescribed methadone and medication for alcohol withdrawal. He was found unresponsive in his cell shortly before 9.00pm on 3 October 2011; the recorded medical cause of death was methadone intoxication, with alcohol withdrawal in a chronic alcoholic also identified. Concerns included communication between medical practitioners and custody staff, inconsistent observation levels, joint training, and training on drug and alcohol-related risks.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels
Wider context from the report “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical record.
” Source location Name not published · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient training emphasis on correct observation levels
Wider context from the report “3. That training should provide targeted emphasis on the correct levels of observation .
” Source location Name not published · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to specify detainee observation levels precisely
Wider context from the report “4. That consideration should be given to eliminating the phrase ‘continue observations at the current level’ and require that doctors and custody sergeants specify the level of observation precisely .
” Source location Name not published · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue guidance requiring medical practitioners to provide custody sergeants with verbal consultation updates.
Verbatim wording from the response “1. Guidance has been issued to all custody trained staff and our medical services provider, Nestor Primcare, to ensure that a verbal update is given by the medical practitioner to the appropriate Custody Sergeant following any consultation of a detained person by such a medical practitioner within the custody environment. This will be captured within Force Policy which is being reviewed currently, and tested through the monthly QA process already in place.” Source location 2015-0138-Response-by-Staffordshire-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Force Policy to incorporate the verbal medical consultation update requirement.
Verbatim wording from the response “1. Guidance has been issued to all custody trained staff and our medical services provider, Nestor Primcare, to ensure that a verbal update is given by the medical practitioner to the appropriate Custody Sergeant following any consultation of a detained person by such a medical practitioner within the custody environment. This will be captured within Force Policy which is being reviewed currently, and tested through the monthly QA process already in place.” Source location 2015-0138-Response-by-Staffordshire-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Detention and Custody Authorised Professional Practice to consider guidance on medical practitioner–custody sergeant consultation, observation levels and detailed medical records.
Verbatim wording from the response “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainees custody medical record.” Source location 2015-0138-Response-by-College-of-Policing
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider further training to supplement and enhance observation-level guidance.
Verbatim wording from the response “3. Further guidance has recently been issued with regard to the correct levels of observation, although we will consider further training to supplement and enhance this guidance.” Source location 2015-0138-Response-by-Staffordshire-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide mandatory custody-officer training on setting observation levels during induction, aligned with current custody guidance.
Verbatim wording from the response “3. G4S always have and continue to provide mandatory training as regards setting the levels of observation to each of its custody officers as part of an initial induction training programme. That training was taught in conjunction with PACE and later (and now) also in conjunction with the Association of Chief Police Officers Guidance on the Safer Detention and Handling of Person in Police Custody 2012 (“ACPO”) and the College of Policing Authorised Professional Practice Guidance “APP”.” Source location 2015-0138-Response-by-G4S1
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain training standards that emphasise selecting correct detainee observation levels and direct users to Authorised Professional Practice.
Verbatim wording from the response “3. That training should provide targeted emphasis on the correct levels of observation.” Source location 2015-0138-Response-by-College-of-Policing
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Instruct custody officers and medical practitioners to record agreed observation levels and avoid non-specific continuation phrases.
Verbatim wording from the response “4. Custody Officers and medical practitioners have been instructed to specify the agreed level of observation within the custody record and to avoid the use of such phrases as ‘I agree with the current observation level’ or ‘Continue observations at the current level’. This will be monitored within the monthly monitoring process and feedback provided where necessary.” Source location 2015-0138-Response-by-Staffordshire-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add advice to Detention and Custody Authorised Professional Practice requiring doctors and custody sergeants to specify observation levels precisely.
Verbatim wording from the response “4. That consideration should be given to eliminating the phrase ‘continue observations at the current level’ and require that doctors and custody sergeants specify the level of observation precisely.” Source location 2015-0138-Response-by-College-of-Policing
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing training standards already emphasise the importance of correct observation levels and refer to applicable guidance.
Verbatim wording from the response “3. That training should provide targeted emphasis on the correct levels of observation.” Source location 2015-0138-Response-by-College-of-Policing
Open published response
Concerns raised 2
Failure to record changes to detainee observation levels View source Failure to implement and record required detainee observation levels View source
This report raised 27 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
South Yorkshire Police
Remind custody staff to record all decisions about detainee checks in custody records.
View source
South Yorkshire Police
Implement digital custody records requiring electronic recording of checks, observations, assessments and associated audit times.
View source
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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 record changes to detainee observation levels
Wider context from the report “(22) No note was made in the custody record of the decision to place the prisoner back on 30 minute checks after the retching episode so that later officers would be aware.
” Source location Neil Budziszewski · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to implement and record required detainee observation levels
Wider context from the report “(6) The afternoon custody sergeant at Ecclesfield failed to place Mr Budziszewski on 30 minute routine checks in breach of PACE Code C (paragraph 9.3). Indeed, there was no annotation on the custody record of the level of checks required
” Source location Neil Budziszewski · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind custody staff to record all decisions about detainee checks in custody records.
Verbatim wording from the response “This is contrary to training which has been provided. All staff have now been reminded that all decisions regarding checks of detainees must be recorded on the custody record and that if the decision is not recorded then the decision has not been made. This was dealt with custody Inspectors on 15 April 2015 and other staff will be reminded of this requirement in a briefing document by the end of May 2015.” Source location 2015-0109-Response-by-South-Yorkshire-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement digital custody records requiring electronic recording of checks, observations, assessments and associated audit times.
Verbatim wording from the response “It is accepted that Mr Budziszewski should have been on 30 minute rousing checks and that this should have been annotated on the custody record when the checks were undertaken. South Yorkshire police have now moved to fully digital custody records and each check will have to be placed onto the electronic custody record. This system has been in place since 17 February 2015 and it is mandated that the checks have to be carried out. The appropriate checks are preselected in a drop down menu on the electronic system and therefore clearly defined according to the appropriate guidance.” Source location 2015-0109-Response-by-South-Yorkshire-Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Thirty-minute checks were unnecessary at Bridge Street because the detainee was never placed in a cell and remained under constant supervision.
Verbatim wording from the response “It is also the case that the risk assessment, once the detainee arrived at Bridge Street, did not refer to the requirement for 30 minute checks because he was never taken to a cell at Bridge Street and therefore under constant supervision. It is right that if he had been taken to a cell then the record would have been updated with the appropriate check times required.” Source location 2015-0109-Response-by-South-Yorkshire-Police
Open published response
6 Jan 2014 Billy Paul Thomas Salton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Lack of understanding of required custody observation levels and rationale View source Failure to transfer and replicate medical observation information during GEO AMEY custody View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
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 Lack of understanding of required custody observation levels and rationale
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
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 transfer and replicate medical observation information during GEO AMEY custody
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
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend MEDACS observation-level dropdown menus to improve clarity.
Verbatim wording from the response “To improve clarity on levels of observations we have amended the ‘drop down’ menus accessible to the MEDACS clinicians attending custody suites. Plans are in place to enable MEDACS to directly input their care plans onto our custody system which will further improve communication between custody and clinical practitioners.” Source location 2014-0002-Response-by-Greater-Manchester-Police
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.