Recurring concern

Unreliable transfer and consideration of medical information during custody transitions

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First reported 6 Jan 2014•Latest report 22 Mar 2024

Definition

What this concern includes

Includes failures of the custody-transition medical-information process, including transferring, retrieving, reading, considering, accurately recording or replicating custody medical assessments, records and related safety requirements for detained people moving between custody settings or into prison healthcare.

Not included

Excludes generic clinical record-keeping deficiencies where no custody-transition or custody-to-prison healthcare information process is implicated.
Excludes failures of clinical assessment or treatment where relevant custody medical information was available and the concern is the subsequent clinical decision.
Excludes general custody handover, observation or prisoner-transfer deficiencies that do not specifically concern transfer and consideration of medical information.
Excludes information-sharing failures between prison healthcare and prison staff that are unrelated to a custody transition or the receipt and review of custody medical information.

Reports: 8
Individual concerns: 8
Date range: 2014–2024
Stated actions: 8

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Betsi Cadwaladr University LHB1

Cardiff Prison1

Cardiff & Vale University LHB1

Care UK1

Egton Medical Information Systems Limited1

GeoAmey PECS Limited1

Greater Manchester Police1

HM Prison and Probation Service1

Home Office1

Medacs Healthcare Limited1

Metropolitan Police Service1

Ministry of Justice1

NHS England1

North Wales Police1

Oxleas NHS Foundation Trust1

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.

22 Mar2024
East Sussex
Concerns raised1
1. Delays in transferring medical information to prison healthcare staff
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Undertake an internal review of EMIS Web interoperability and medical-record transfer issues raised in the report.
  Stated by Egton Medical Information Systems LimitedStated completed
2. Action
  Maintain compliance with the latest NHS England GP2GP specifications and associated processes for electronic medical-record transfers.
  Stated by Egton Medical Information Systems LimitedStated completed
3. Action
  Continue reviewing EMIS solutions to identify potential performance improvements affecting medical-record transfers.
  Stated by Egton Medical Information Systems LimitedStated in progress
1. Action
  Enable functionality supporting automatic electronic transfer of prisoners’ full community GP records to prison GPs and back on release.
  Stated by The Phoenix Partnership (Leeds) LtdStated completed
Respondent positions 2
1. Position
  Existing GP2GP functionality and NHS England specification compliance sufficiently mitigate the identified medical-record transfer risks; no further software development is required.
  Stated by Egton Medical Information Systems LimitedExisting arrangements considered sufficient
1. Position
  GP data controllers are responsible for permitting data sharing and enabling the relevant reciprocal controls under data protection legislation.
  Stated by The Phoenix Partnership (Leeds) LtdRedirects responsibility
AI-generated summary

Finlay Stuart Ian FINLAYSON · 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

Finlay Stuart Ian FINLAYSON died following cardiac arrest at HMP Lewes on 25 January 2019; the stated causes were pulmonary thromboemboli due to deep vein thrombosis, against a background of metastatic carcinoma of the base of the tongue. Concerns included delays and possible omissions in transferring medical information between healthcare systems, poor record keeping, communication failures, delays in accessing healthcare, and failures in the emergency response.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in transferring medical information to prison healthcare staff
Wider context from the report
“During the course of the Inquest the jury heard evidence about the difficulty in information being transferred over from Mr Finlayson's GP surgery system, which uses SystmOne to the prison system (also SystmOne). The evidence was that information was not able to be freely shared between the two and it meant that there was a delay in healthcare staff in the prison accessing relevant information about Mr Finlayson's long term health issues as well as contact with his GP as recent as a week before going in to prison. Mr Finlayson sadly died in 2019 and I have heard evidence that the functioning of SystmOne has improved since his death. I was told, however, that there remains an issue with the interaction between SystmOne and other medical databases used in England and Wales. SystmOne appears to be the preferred system for many prisons and detention centres but there are still many GP surgeries that use other systems. I heard evidence that if someone goes to prison and is linked to a surgery that uses another system (like EMIS) the notes have to be printed and scanned on to SystmOne and key information has to be input onto someone's record by hand. I am concerned about the potential delay this process could cause. I am also concerned that key information could be missed by virtue of these systems not communicating with each other. I have heard evidence as to the importance of someone's medical history being available for those within the prison setting to assist with careplanning and the provision of appropriate care and in my opinion, there is a risk that future deaths could occur unless action is taken to make the transfer of this information more efficient. ”
Source location
Finlay Stuart Ian FINLAYSON · 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
Undertake an internal review of EMIS Web interoperability and medical-record transfer issues raised in the report.

Verbatim wording from the response
“We have undertaken an internal review of EMIS Web, focussing on the issues raised as areas of concern in the Report in relation to EMIS Web, namely a potential lack of interaction between clinical systems in prisons (predominantly SystmOne) and other clinical systems in community GP surgeries, and the evidence you heard that notes have to be printed and scanned on to SystmOne, with key information inputted manually, if an individual’s GP practice uses a clinical system other than SystmOne.”

Source location
Response from EMIS
Page 1 · response
Published 25 March 2024
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
Maintain compliance with the latest NHS England GP2GP specifications and associated processes for electronic medical-record transfers.

Verbatim wording from the response
“EMIS are fully compliant, and have processes in place to remain compliant, with the latest versions of the NHS England GP2GP specification. Therefore, EMIS practices can receive medical record requests from prisons and return the requested information via the GP2GP process. EMIS practices also have the option to send printed medical records via courier when medical requests are not received from prisons via GP2GP (at the prison’s discretion). In either scenario, EMIS would not have any control over whether the prison requests the medical records via the GP2GP process, or via a manual process.”

Source location
Response from EMIS
Page 2 · response
Published 25 March 2024
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
Continue reviewing EMIS solutions to identify potential performance improvements affecting medical-record transfers.

Verbatim wording from the response
“As detailed above, EMIS is compliant with NHS England GP2GP specifications, and we will continue to review our solutions to determine whether any performance improvements can be made. However, based on the information provided in the Report, and our subsequent review, we do not believe in this instance there are any software developments, beyond the existing functionality in the System, that are required to mitigate the specific risks raised in the Report.”

Source location
Response from EMIS
Page 2 · response
Published 25 March 2024
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
Enable functionality supporting automatic electronic transfer of prisoners’ full community GP records to prison GPs and back on release.

Verbatim wording from the response
“Since the time of Mr Finlayson’s death, more has been done to improve matters. Full GP registration (‘GMS’) has been introduced into prisons in the last two years as a result of policy change by NHS England. Functionality was enabled by TPP to enact this policy change. As a result, prisoners can now opt to have their community GP registration (and their community GP record) transferred to the prison GP. This involves the automatic electronic transfer of the full community GP record to the prison GP, which is then transferred out again on release of the prisoner to the community GP practice. This is an enormous improvement. This change applies regardless of whether the community GP practice uses SystmOne or EMIS.”

Source location
Response from TPP
Page 1 · response
Published 25 March 2024
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 GP2GP functionality and NHS England specification compliance sufficiently mitigate the identified medical-record transfer risks; no further software development is required.

Verbatim wording from the response
“As detailed above, EMIS is compliant with NHS England GP2GP specifications, and we will continue to review our solutions to determine whether any performance improvements can be made. However, based on the information provided in the Report, and our subsequent review, we do not believe in this instance there are any software developments, beyond the existing functionality in the System, that are required to mitigate the specific risks raised in the Report.”

Source location
Response from EMIS
Page 2 · response
Published 25 March 2024
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
GP data controllers are responsible for permitting data sharing and enabling the relevant reciprocal controls under data protection legislation.

Verbatim wording from the response
“Your report highlights that information was not freely shared between the GP (using SystmOne) and the prison service. Functionality to allow seamless sharing of data is available within SystmOne, and this functionality was available to the detained estate (including prisons) from well before 2019. However, as is still the case, the sharing of data is dependent on the data controller (in this case the GP) permitting the data to be made available to other healthcare organisations. This responsibility is set out in UK Data Protection Legislation. Without the control in SystmOne being turned on by the GP data controller (and a reciprocal control on the receiving side being enabled) the data is not visible. Dame Fiona Caldicott and other data champions have tried to make information sharing ‘the norm’ but there is still resistance in many areas.”

Source location
Response from TPP
Page 1 · response
Published 25 March 2024
Open published response
12 Mar2020
South Wales Central
Concerns raised1
1. Failure to review System 1 and medical records on prison admission
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  Implementing a red-flag system requires partnership with the technology provider, health authorities and other prisons because it would affect all prisons.
  Stated by Cardiff & Vale University LHBRedirects responsibility
1. Position
  Existing dual screening reviews, supported by prison staff reviewing records and sharing important information, are considered sufficient for new admissions.
  Stated by Cardiff & Vale University LHBExisting arrangements considered sufficient
AI-generated summary

IAN JAMES WEEKS · 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

Ian Weeks was remanded into custody at HMP Cardiff and was later found to have hung himself from the shower rail in his cell, sometime between 20 and 21 October 2017. The concerns included that healthcare staff did not check records showing a recent suicide attempt or notice that he had been prescribed antidepressants, and that there was no effective process for reviewing System 1 records or a suicide and self-harm warning flag.

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 System 1 and medical records on prison admission
Wider context from the report
“(1) Although it was recorded on System 1 that Mr Weeks had recently attempted suicide in another prison shortly before his admission to HMP Cardiff no member of Healthcare staff checked the medical records and further that although the GP records which were sent to the prison confirmed that Mr Weeks was prescribed anti-depressants in the community no member of Healthcare staff noticed this and as a consequence Mr Weeks was not given anti-depressants in HMP Cardiff. The Healthcare witnesses, including the Head of Healthcare, indicated that a red flag for suicide or self-harm would be of great value for staff who because of insufficient staff and a heavy workload did not have time to review the System 1 record in any or any sufficient detail. Further it was considered that all System 1 records should be reviewed when an individual is admitted into the prison and that there should be in place a process for doing so. ”
Source location
IAN JAMES WEEKS · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Implementing a red-flag system requires partnership with the technology provider, health authorities and other prisons because it would affect all prisons.

Verbatim wording from the response
“In order to pursue a red flag system, a partnership with TPP (SystmOne technology provider), NHS England, NHS Wales Informatics Service (NWIS) and other prisons will be required as this would be a change that would affect all prisons. The clinical team from HMP Cardiff intend to raise this issue at their next All Wales Prison Healthcare Meeting which Public Health Wales and Welsh Government also attend.”

Source location
2020-0064-Response-from-Cardiff-and-Vale-NHS-Trust-1
Page 2 · response
Published 27 March 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing dual screening reviews, supported by prison staff reviewing records and sharing important information, are considered sufficient for new admissions.

Verbatim wording from the response
“As indicated, a large volume of information is contained within SystmOne. Existing process is for healthcare staff in the prison to undertake two screening reviews of new individuals in order to assess and plan their care. This is done in conjunction with prison staff who also review the SystmOne records and share important information.”

Source location
2020-0064-Response-from-Cardiff-and-Vale-NHS-Trust-1
Page 3 · response
Published 27 March 2020
Open published response
29 Oct2018
Inner South London
Concerns raised1
1. Failure to establish a fail-safe mechanism for medical staff in prison to see and consider custody assessments and records
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Attach relevant medical information to the Person Escort Record when detainees leave custody, including information identifying increased health risks.
  Stated by Metropolitan Police ServiceStated completed
2. Action
  Introduce the revised Person Escort Record with additional health, social-care and risk information for transfers between partner agencies.
  Stated by Metropolitan Police ServiceStated planned
3. Action
  Continue training and partnership working to improve medical-information handover and management of detainee health risks.
  Stated by Metropolitan Police ServiceStated in progress
Respondent positions 3
1. Position
  Prison-service actions concerning DPMF access and availability fall beyond the MPS’s responsibility to influence.
  Stated by Metropolitan Police ServiceOutside remit
1. Position
  HMPPS leads the project to change the Person Escort Record and mitigate risks when detainees transfer between partner agencies.
  Stated by Metropolitan Police ServiceRedirects responsibility
2. Position
  NHS England and HMPPS are developing the electronic Person Escort Record, including medication information.
  Stated by Metropolitan Police ServiceRedirects responsibility
AI-generated summary

Mr Thomas Patrick McAuley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Thomas Patrick McAuley was found dead in his prison cell on 23 August 2017. The medical cause of death was bronchopneumonia, with chronic bronchitis and alcohol and drug dependence also recorded. The inquest identified concerns about clinical information from police custody not being available to all prison clinical staff and a lack of clinical observations during the first five days of methadone treatment.

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 establish a fail-safe mechanism for medical staff in prison to see and consider custody assessments and records
Wider context from the report
“6. In conclusion, there is no assurance that doctors attending in custody, the prison service and those providing health care in prisons have established a fail-safe mechanism of ensuring that medical assessments on vulnerable individuals and records from custody are seen and considered by medical staff in prison. ”
Source location
Mr Thomas Patrick McAuley · 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
Attach relevant medical information to the Person Escort Record when detainees leave custody, including information identifying increased health risks.

Verbatim wording from the response
“Prior to departure, custody staff complete a Person Escort Record (PER) and give the form to SERCO officers. If the detainee has been assessed by a Health Care Professional (HCP) in custody, the HCP will complete a Detained Person’s Medical Form (DPMF). The purpose of the DPMF is to highlight areas of medical concern to custody staff, and to provide, where necessary, a chronological medical report relating to a detainee’s period of detention. The information contained in the DPMF together with a risk assessment contribute to the safe and effective detention of the detainee. The MPS Custody Policy states that the DPMF (where applicable) is to be included in the documentation attached to the PER and should be referred to in the ‘escort handover’ page.”

Source location
2018-0309-Response-by-Metropolitan-Police
Page 2 · response
Published 17 February 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Introduce the revised Person Escort Record with additional health, social-care and risk information for transfers between partner agencies.

Verbatim wording from the response
“There is currently work in progress to change the PER to mitigate such risks when transferring a detainee between partner agencies. HMPPS are leading on this project, which includes attaching additional documentation and notes to highlight the increased risks to partner agencies. The new PER will contain additional health and social care information, which will mitigate the identified risks when vulnerable people are being transferred between the police escort contractors and HMPPS custody. It is anticipated that this project will be completed and delivered by April 2019.”

Source location
2018-0309-Response-by-Metropolitan-Police
Page 3 · response
Published 17 February 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue training and partnership working to improve medical-information handover and management of detainee health risks.

Verbatim wording from the response
“The MPS will continue to attach all relevant medical information to the PER when detainees leave our custody suites to highlight any increased health risks. We are committed to continual training and partnership working and in the short-term it is anticipated by April 2019 the new PER will be introduced, which will seek to address limitations on the current PER. The MPS has also supported the dissemination of the learning opportunities presented by your report through engagement with NOMS. NHS England and HMPPS leads in the preparation of this response and as a result, we have been invited to evaluate and comment on the ePER. The MPS will be introducing the EMRS platform, hopefully within one year, which will enable the medical assessments and treatments of vulnerable individuals to be considered by medical staff in prison.”

Source location
2018-0309-Response-by-Metropolitan-Police
Page 3 · response
Published 17 February 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Prison-service actions concerning DPMF access and availability fall beyond the MPS’s responsibility to influence.

Verbatim wording from the response
“Matters 1-4 relate to actions of the prison service and are beyond the responsibility of the MPS to influence. Matters 5-6 raise issues relating specifically to police handover of detainees and sharing of medical information; we have responded to these below:”

Source location
2018-0309-Response-by-Metropolitan-Police
Page 2 · response
Published 17 February 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
HMPPS leads the project to change the Person Escort Record and mitigate risks when detainees transfer between partner agencies.

Verbatim wording from the response
“There is currently work in progress to change the PER to mitigate such risks when transferring a detainee between partner agencies. HMPPS are leading on this project, which includes attaching additional documentation and notes to highlight the increased risks to partner agencies. The new PER will contain additional health and social care information, which will mitigate the identified risks when vulnerable people are being transferred between the police escort contractors and HMPPS custody. It is anticipated that this project will be completed and delivered by April 2019.”

Source location
2018-0309-Response-by-Metropolitan-Police
Page 3 · response
Published 17 February 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NHS England and HMPPS are developing the electronic Person Escort Record, including medication information.

Verbatim wording from the response
“There is also further work being undertaken by NHS England and HMPPS to develop an electronic version of the PER (ePER) with information regarding medications included. The ePER is being used in five prisons and is being piloted by Surrey Police. The MPS understand that, by the time the new PECS contract is operational (late 2020) the product will be fully digital. In the interim period, whilst these innovations are taking place, the MPS will continue to ensure that any relevant medical information available on NSPSIS is also recorded in the PER.”

Source location
2018-0309-Response-by-Metropolitan-Police
Page 3 · response
Published 17 February 2019
Open published response
6 Dec2016
Inner North London
Concerns raised1
1. Failure to transfer person escort and forensic medical records to nurse reception screening
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Require nurses to confirm they have seen the person escort record and possess the CSRA and PER before completing reception screening.
  Stated by Care UKStated completed
AI-generated summary

Tedros Habtom KAHSSAY · 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

Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring first aid.

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 transfer person escort and forensic medical records to nurse reception screening
Wider context from the report
“1. The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr Kahssay to HMP Pentonville did not accompany him to nurse reception screening. ”
Source location
Tedros Habtom KAHSSAY · 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
Require nurses to confirm they have seen the person escort record and possess the CSRA and PER before completing reception screening.

Verbatim wording from the response
“As you heard in evidence at the inquest, the reception screening template has been changed. The change that has been implemented is a control question in the first reception screen which is a mandatory field so the nurse needs to stop and answer the question. It asks if the nurse has seen the PER. All nursing staff have been instructed and are aware that they are not to screen any prisoner without a CSRA and PER as minimum requirement to aid screening.”

Source location
2016-0437-Response-by-Care-UK.pdf
Page 1 · response
Published 6 December 2016
Open published response
27 May2016
South Yorkshire (Eastern)
Concerns raised1
1. Failure to ensure transfer of medical records from previous custodial establishments
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Adetokunbo Ohisaga Ajakaiye · 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

Adetokunbo Ohisaga Ajakaiye was arrested on 13 November 2010, transferred to HMP Doncaster, and later taken to hospital, where he died of malaria early on 25 November 2010. Concerns included healthcare staff’s lack of practical experience and knowledge concerning malaria and tropical diseases, and the failure of medical records from earlier custodial establishments to accompany him to HMP Doncaster.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure transfer of medical records from previous custodial establishments
Wider context from the report
“1. When Mr Ajakaiye arrived at HMP Doncaster on 15th November 2010 it appears that his medical records from Heathrow Airport Police Station and Lawcroft House Police Station did not accompany him. The doctor who saw Mr Ajakaiye, on 16th November 2010, stated, in her evidence, that it would have assisted her in her diagnosis had she had those medical records available to her at that appointment. The court heard that, whilst the medical records from previous custodial establishments sometimes accompanied the Prisoner Escort Records, it was not infrequently the case that they did not. ”
Source location
Adetokunbo Ohisaga Ajakaiye · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Aug2015
North Wales (East and Central)
Concerns raised1
1. Failure to provide the Transfer of Care Form to escorting police for immediate availability to the custody nurse
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Andrew Selwyn Roberts · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Andrew Selwyn Roberts was arrested on 24 December 2011, after being tasered and having taken an overdose, and was taken to hospital before being assessed as fit to return to custody. The transfer of care form inaccurately stated that he had been assessed by psychiatric liaison, although he had not been seen by that team. The substantive concerns were that the form was completed by a nurse rather than the examining doctor, contained inaccurate information, and was not completed and provided to police at the time of examination.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide the Transfer of Care Form to escorting police for immediate availability to the custody nurse
Wider context from the report
“2. That the Transfer of Care Form was not completed at the time of examination and provided to the Police Officers escorting the detained person to hospital so that it could be returned with them to custody and made immediately available to the custody nurse. ”
Source location
Andrew Selwyn Roberts · Prevention of Future Deaths report
Page 2 · concerns
Open source report
11 Mar2014
Cardiff & the Vale of Glamorgan
Concerns raised1
1. Lack of medical or hospital treatment information in the Person Escort Record
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Christopher Shapley · 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

Christopher Shapley was arrested on 17 September 2013, remanded in custody, and taken to HMP Cardiff after treatment at hospital for alcohol withdrawal symptoms and fitting. He was placed alone in a cell and found hanged during morning checks on 20 September 2013. Concerns included incomplete transfer of information about his hospital treatment and self-harm risks, insufficient assessment of risk factors, inadequate efforts to arrange a shared cell, and inadequate handover and night-time observations.

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 medical or hospital treatment information in the Person Escort Record
Wider context from the report
“(1) The jury found it of concern that the information that Christopher Shapley had been in Prince Charles Hospital after arrest was not known to the prison. Had it been known his condition may, they felt, have been treated more seriously and he would have been kept under greater observation. There would seem to be no reason why the PER (Person Escort Record) could not contain a section dealing with medical or hospital treatment received while in police custody prior to remand (e.g. the section at the foot of page 2 could also include a prompt for any health treatment received). This information will not only advise prison staff of the current medical circumstances of the prisoner but will also prompt them to call for any hospital discharge notes (or consult with the Force Medical Examiner) so that effective treatment can be continued. ”
Source location
Christopher Shapley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
6 Jan2014
Manchester South
Concerns raised1
1. Failure to transfer and replicate medical observation information during GEO AMEY custody
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

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 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
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in transferring medical information to prison healthcare staff

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to review System 1 and medical records on prison admission

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to establish a fail-safe mechanism for medical staff in prison to see and consider custody assessments and records

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

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

Concerns raised1

Failure to transfer person escort and forensic medical records to nurse reception screening

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to ensure transfer of medical records from previous custodial establishments

Concerns raised1

Failure to provide the Transfer of Care Form to escorting police for immediate availability to the custody nurse

Concerns raised1

Lack of medical or hospital treatment information in the Person Escort Record

Concerns raised1

Failure to transfer and replicate medical observation information during GEO AMEY custody

Actions described in response 4

Respondent positions 2

Respondent positions 2

Actions described in response 3

Respondent positions 3

Actions described in response 1