Recurring concern

Inadequate prison mental healthcare for people requiring hospital-level treatment

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First reported 20 May 2024•Latest report 24 Nov 2025

Definition

What this concern includes

Includes failures in prison-based mental healthcare arrangements for people whose needs require hospital-level, secure or specialist mental health treatment, including inability to provide clinically necessary compulsory treatment, inadequate secondary mental healthcare and failures to provide appropriate therapeutic or psychological care while transfer or admission is delayed.

Not included

Excludes general prison healthcare access or operating-hours deficiencies where hospital-level or specialist mental health treatment is not the material concern.
Excludes secure mental health bed-capacity or transfer-delay assertions where prison mental healthcare inadequacy is not also identified.
Excludes generic mental health service shortages, routine psychiatric follow-up and community mental healthcare unless the assertion directly concerns prison-based care for people requiring hospital-level or specialist treatment.
Excludes failures in individual medication, observation or treatment decisions where the wider inadequacy of prison mental healthcare is not the unsafe condition.

Reports: 3
Individual concerns: 4
Date range: 2024–2025
Stated actions: 16

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.

NHS England3

Ministry of Justice2

Berkshire Healthcare NHS Foundation Trust1

Department of Health and Social Care1

Greater Manchester Mental Health NHS Foundation Trust1

HM Inspectorate of Prisons1

HM Prison and Probation Service1

Home Office1

Midlands Partnership University NHS Foundation Trust1

Oxford Health NHS Foundation Trust1

Prisons and Probation Ombudsman1

Spectrum Community Health C.I.C.1

Styal Prison and Young Offender Institution1

Thames Valley Police1

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.

24 Nov2025
Surrey
Concerns raised2
1. Inability of prison healthcare provision to fully meet mental health patients’ needs
2. Inability to provide compulsory medication and treatment in prison
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Complete an independent review of HMP Bronzefield healthcare provision and submit its findings to the Prisons and Probation Ombudsman.
  Stated by NHS EnglandStated completed
2. Action
  Develop and submit an action plan addressing findings from the HMP Bronzefield healthcare review.
  Stated by NHS EnglandStated completed
Respondent positions 1
1. Position
  Existing local actions are considered appropriate to address the healthcare issues identified at HMP Bronzefield.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
AI-generated summary

Diana Ocean Grant · 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

Diana Ocean Grant, who was experiencing a relapse of paranoid schizophrenia and symptoms of psychosis, died in her prison cell after a foreign object became lodged in her upper airway. The report identified concerns about failures and delays in mental health assessment, treatment, information-sharing, observation and prison placement, as well as the limited availability of secure mental health beds for people requiring admission.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inability of prison healthcare provision to fully meet mental health patients’ needs
Wider context from the report
“The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise. The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate, but also because of an expectation that some element of pre-planning will take place before such an admission occurs. Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days. Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing. This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments. Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison. The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed. ”
Source location
Diana Ocean Grant · Prevention of Future Deaths report
Page 6 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inability to provide compulsory medication and treatment in prison
Wider context from the report
“The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise. The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate, but also because of an expectation that some element of pre-planning will take place before such an admission occurs. Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days. Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing. This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments. Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison. The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed. ”
Source location
Diana Ocean Grant · Prevention of Future Deaths report
Page 6 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Complete an independent review of HMP Bronzefield healthcare provision and submit its findings to the Prisons and Probation Ombudsman.

Verbatim wording from the response
“An independent review of the healthcare provision at HMP Bronzefield was commissioned and submitted to the Prisons and Probation Ombudsman (PPO) in February 2023. The PPO’s final report was published in January 2025. Alongside Sodexo, the Clinical Lead for Central and North West London NHS Foundation Trust was involved with developing an action plan in May 2023 and this was submitted to the PPO.”

Source location
Response from NHS England
Page 2 · response
Published 1 December 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and submit an action plan addressing findings from the HMP Bronzefield healthcare review.

Verbatim wording from the response
“An independent review of the healthcare provision at HMP Bronzefield was commissioned and submitted to the Prisons and Probation Ombudsman (PPO) in February 2023. The PPO’s final report was published in January 2025. Alongside Sodexo, the Clinical Lead for Central and North West London NHS Foundation Trust was involved with developing an action plan in May 2023 and this was submitted to the PPO.”

Source location
Response from NHS England
Page 2 · response
Published 1 December 2025
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 local actions are considered appropriate to address the healthcare issues identified at HMP Bronzefield.

Verbatim wording from the response
“NHS England has advised that, since April 2023, its South East Health and Justice team has commissioned the full healthcare provision at HMP Bronzefield, including primary care, substance misuse and mental health services. An independent review of healthcare provision at the prison was completed and submitted to the Prisons and Probation Ombudsman in February 2023, and an action plan was subsequently developed with the provider to address the findings. NHS England has confirmed that the London Region is satisfied that appropriate actions have been taken locally in response to the issues identified at inquest.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 1 December 2025
Open published response
2 May2025
Cheshire
Concerns raised1
1. Insufficient mental health team capacity for women awaiting assessment or inpatient beds
This report raised 7 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

Sarah Frances BOYLE · 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

Sarah Boyle was detained at HMP Styal and was monitored under the ACCT process after expressing thoughts of self-harm or suicide and making several ligature attempts. On 14 July 2024, she was found with a ligature around her neck, suffered irreversible brain damage, and died in hospital on 20 July 2024. The report raises concerns that the ACCT process at HMP Styal was not working effectively, citing high levels of self-harm, complex mental-health needs, understaffing, missed checks, and inconsistent completion of the process.

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
Insufficient mental health team capacity for women awaiting assessment or inpatient beds
Wider context from the report
“I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths. My concerns are based on the following points which I heard in evidence: • HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in; • I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting; • It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025); • I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents; • The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed; • The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed; • Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training. The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”. In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest. ”
Source location
Sarah Frances BOYLE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 May2024
Central Criminal Court
Concerns raised1
1. Failure to provide adequate secondary mental healthcare in prison
This report raised 5 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 14
1. Action
  Strengthen community-custody transitions through proactive Prison and Probation engagement, named-worker handovers and explicit responsibility arrangements.
  Stated by Berkshire Healthcare NHS Foundation TrustStated planned
2. Action
  Improve Pathfinder delivery by redefining partner responsibilities and linking Pathfinder forums with the Counter Terrorism Clinical Consultancy Service.
  Stated by Ministry of JusticeStated in progress
3. Action
  Refresh the psychology pathway and update referral criteria.
  Stated by Midlands Partnership University NHS Foundation TrustStated completed
1. Action
  Standardise psychological care pathway practice across prisons.
  Stated by Midlands Partnership University NHS Foundation TrustStated in progress
2. Action
  Develop a pilot introducing Mental Health and Wellbeing Practitioner roles in Health in Justice services.
  Stated by Midlands Partnership University NHS Foundation TrustStated completed
3. Action
  Provide staff with ongoing training in psychological care, including CBT, DBT, trauma-informed care and co-occurring conditions.
  Stated by Midlands Partnership University NHS Foundation TrustStated completed
4. Action
  Review current mental health service provision for adults in contact with the criminal justice system.
  Stated by NHS EnglandStated in progress
5. Action
  Develop a Mental Health Criminal Justice Pathway through the Health and Justice Mental Health Pathway Expert Working Group.
  Stated by NHS EnglandStated in progress
6. Action
  Re-procure and provide secondary mental health services at HMP Bullingdon and HMP Huntercombe through Oxford Health NHS Foundation Trust.
  Stated by NHS EnglandStated completed
7. Action
  Operate an integrated primary and secondary prison mental healthcare model with access to health and community mental health records.
  Stated by NHS EnglandStated completed
8. Action
  Prioritise increased access to evidence-based talking therapies while developing a more sustainable workforce to deliver them in prisons.
  Stated by NHS EnglandStated in progress
9. Action
  Introduce two band 5 psychological wellbeing practitioner posts at HMP Bullingdon.
  Stated by Oxford Health NHS Foundation TrustStated planned
10. Action
  Submit a business case to commissioners proposing staffing alternatives to increase and expand psychological provision at HMP Huntercombe.
  Stated by Oxford Health NHS Foundation TrustStated completed
11. Action
  Consider introducing guidance on recording declined psychological treatment offers and reviewing them in caseload management supervision.
  Stated by Oxford Health NHS Foundation TrustStated planned
Respondent positions 6
1. Position
  For longer custodial sentences requiring ongoing mental health input, responsibility transfers from community services to prison mental health services, with handover.
  Stated by Berkshire Healthcare NHS Foundation TrustRedirects responsibility
1. Position
  Operational delivery of mental healthcare is the responsibility of relevant NHS trusts.
  Stated by Ministry of JusticeRedirects responsibility
2. Position
  HMPPS has limited levers to secure healthcare attendance at Pathfinder meetings or escalate gaps in mental health services.
  Stated by Ministry of JusticeUnable to act
3. Position
  Employing more psychological practitioners in prisons is not possible because of current budget constraints.
  Stated by Midlands Partnership University NHS Foundation TrustUnable to act
4. Position
  Oxford Health NHS Foundation Trust is required to provide assurance about current practices and psychological services at Bullingdon and Huntercombe prisons.
  Stated by NHS EnglandRedirects responsibility
5. Position
  Psychological provision at HMP Huntercombe cannot currently be increased because staffing posts remain unfilled pending a commissioners’ decision on the proposed staffing model.
  Stated by Oxford Health NHS Foundation TrustUnable to act
AI-generated summary

James Furlong and 2 others · Prevention of Future Deaths report

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

Report summary

James Furlong, Joseph Ritchie-Bennett and David Wails were murdered by Khairi Saadallah in a premeditated attack in Forbury Gardens, Reading, on 20 June 2020. The principal concerns were failures by multiple bodies to assess and share intelligence about Saadallah’s risks, provide an adequate integrated response, and provide adequate mental healthcare in the community and prison; the report states these failures probably or possibly contributed to the three deaths.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide adequate secondary mental healthcare in prison
Wider context from the report
“The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to: a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading; b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder); c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison. The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD. The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police) The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust) ”
Source location
James Furlong and 2 others · Prevention of Future Deaths report
Page 4 · 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
Strengthen community-custody transitions through proactive Prison and Probation engagement, named-worker handovers and explicit responsibility arrangements.

Verbatim wording from the response
“Where individuals move between the community and custody, there will be greater proactive engagement with Prison and Probation colleagues both principally and on a case-by-case basis. Where someone receives a short sentence, it would be important to maintain CMHT input and involvement in planning for post release. For more lengthy sentences requiring ongoing mental health input in custody, they will transition from community (e.g. CMHT) to Prison Mental Health Services. In such situations, the named worker in the community will ensure that a handover takes place with prison colleagues. The Reconnect roles, as described above, will allow for easier transition back into CMHT's on release if required.”

Source location
Response from Berkshire Healthcare
Page 7 · response
Published 23 May 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
Improve Pathfinder delivery by redefining partner responsibilities and linking Pathfinder forums with the Counter Terrorism Clinical Consultancy Service.

Verbatim wording from the response
“38. As part of ongoing continuous improvement activities, HMPPS is taking steps to improve how Pathfinder is delivered including re-defining the roles and responsibilities of Pathfinder partners. These include links that have been established between Pathfinder forums and the Counter Terrorism Clinical Consultancy Service (CTCCS) which replaced Vulnerability Support Hubs in April 2024. CTCCS are embedded multi-disciplinary mental health teams that work with individuals who are deemed susceptible to radicalisation and who also present as having mental health issues.”

Source location
Response from Ministry of Justice
Page 11 · response
Published 23 May 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
Refresh the psychology pathway and update referral criteria.

Verbatim wording from the response
“Following the tragic deaths in Forbury Gardens MPFT undertook an internal review; the report summarising the outcome of this internal review was disclosed to the inquest and formed part of the evidence bundle. The internal review identified the need to address psychological care pathways and the management of psychology waiting lists.”

Source location
Response from Midlands Partnership NHS
Page 1 · response
Published 23 May 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
Standardise psychological care pathway practice across prisons.

Verbatim wording from the response
“Action was taken to refresh the psychology pathway, including updating referral criteria. There has been a further piece of work across the Prisons we work in to standardise practice in regard to psychological care pathways which is due to be completed by the end of August 2024.”

Source location
Response from Midlands Partnership NHS
Page 1 · response
Published 23 May 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
Develop a pilot introducing Mental Health and Wellbeing Practitioner roles in Health in Justice services.

Verbatim wording from the response
“MPFT have worked with NHS England to develop a pilot of the Mental Health & Wellbeing Practitioner (MHWP) role which is a new role within some Health in Justice services. This role is one of the newer psychological professions. MHWPs are trained to provide low intensity psychological interventions to people with severe and enduring mental health difficulties.”

Source location
Response from Midlands Partnership NHS
Page 2 · response
Published 23 May 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
Provide staff with ongoing training in psychological care, including CBT, DBT, trauma-informed care and co-occurring conditions.

Verbatim wording from the response
“Staff have access to an ongoing programme of training which supports our overall Psychological care of people in prisons. This includes learning about Cognitive Behavioural Therapy (CBT), Dialectic Behaviour Therapy (DBT), Trauma Informed care and working with co-occurring conditions.”

Source location
Response from Midlands Partnership NHS
Page 2 · response
Published 23 May 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
Review current mental health service provision for adults in contact with the criminal justice system.

Verbatim wording from the response
“The NHS England Mental Health Programme has recently embarked on new work to review the current service provision for adult individuals in contact with the criminal justice system. This has focused on the changes required to provide sustainable and”

Source location
Response from NHS England
Page 1 · response
Published 23 May 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
Develop a Mental Health Criminal Justice Pathway through the Health and Justice Mental Health Pathway Expert Working Group.

Verbatim wording from the response
“To enable these changes, a Mental Health Criminal Justice Pathway is in development. This Pathway is overseen by a ‘Health and Justice Mental Health Pathway Expert Working Group’ and this work aims to:”

Source location
Response from NHS England
Page 2 · response
Published 23 May 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
Re-procure and provide secondary mental health services at HMP Bullingdon and HMP Huntercombe through Oxford Health NHS Foundation Trust.

Verbatim wording from the response
“Additionally, since the tragic events of 20 June 2020, NHS England’s South East region has re-procured mental health services at HMP Bullingdon and HMP Huntercombe. These services are now provided by Oxford Health NHS Foundation Trust (OHFT) at both sites.”

Source location
Response from NHS England
Page 3 · response
Published 23 May 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
Operate an integrated primary and secondary prison mental healthcare model with access to health and community mental health records.

Verbatim wording from the response
“Further to the above, there is an integrated model of mental health care across both primary and secondary care mental health services, with access to the Health and Justice Information Services (HJIS) records, along with community mental health records, to better support continuity of care and information sharing.”

Source location
Response from NHS England
Page 3 · response
Published 23 May 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
Prioritise increased access to evidence-based talking therapies while developing a more sustainable workforce to deliver them in prisons.

Verbatim wording from the response
“The provision of psychological therapies is still commissioned, although recruitment challenges mean there is a longer wait for initial assessment for psychological therapy than is ideal at present. Prison mental health teams do maintain a 5 day wait for routine mental health referrals, however, increasing the availability and accessibility of talking therapies is a priority.”

Source location
Response from NHS England
Page 3 · response
Published 23 May 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
Introduce two band 5 psychological wellbeing practitioner posts at HMP Bullingdon.

Verbatim wording from the response
“At HMP Bullingdon the current staffing model is a 0.8 whole time equivalent (WTE) band 7 psychotherapist, a 0.3 WTE band 8a forensic psychologist, and two band 5 psychological wellbeing practitioners who are currently due to start in the service in July 2024. In the past 12 months there have been 116 referrals for psychology, 17 patients are engaged in therapy currently, and 34 patients waiting. The average waiting time is around 14 weeks. We also have a Consultant Forensic Psychologist who oversees the governance of the psychological therapies pathways within the mental health teams, including managing caseloads of the psychologists and psychological therapists.”

Source location
Response from Oxford Health
Page 2 · response
Published 23 May 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
Submit a business case to commissioners proposing staffing alternatives to increase and expand psychological provision at HMP Huntercombe.

Verbatim wording from the response
“At HMP Huntercombe the current staffing model is one WTE band 4 assistant psychologist and 0.3 WTE band 8a psychologist. The service has not been able to fill these posts and a business case was submitted by the service to commissioners that proposed three alternatives to the staffing model. The purpose of the business case is to give us the best chance to recruit into posts, to increase the provision for psychology and to expand the service which can be offered. The business case has been submitted and we hope to receive a decision in July 2024. There are high levels of trauma within the establishment and the focus will be to treat the trauma and any associated symptoms.”

Source location
Response from Oxford Health
Page 2 · response
Published 23 May 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
Consider introducing guidance on recording declined psychological treatment offers and reviewing them in caseload management supervision.

Verbatim wording from the response
“In terms of actions that it will be helpful for the Trust to consider, the service will consider if they should introduce guidance for psychological therapy staff about what to record when an individual declines treatment in the prison pathway, to include guidance that declined offers of treatment are always considered in caseload management supervision.”

Source location
Response from Oxford Health
Page 3 · response
Published 23 May 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
For longer custodial sentences requiring ongoing mental health input, responsibility transfers from community services to prison mental health services, with handover.

Verbatim wording from the response
“Where individuals move between the community and custody, there will be greater proactive engagement with Prison and Probation colleagues both principally and on a case-by-case basis. Where someone receives a short sentence, it would be important to maintain CMHT input and involvement in planning for post release. For more lengthy sentences requiring ongoing mental health input in custody, they will transition from community (e.g. CMHT) to Prison Mental Health Services. In such situations, the named worker in the community will ensure that a handover takes place with prison colleagues. The Reconnect roles, as described above, will allow for easier transition back into CMHT's on release if required.”

Source location
Response from Berkshire Healthcare
Page 7 · response
Published 23 May 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
Operational delivery of mental healthcare is the responsibility of relevant NHS trusts.

Verbatim wording from the response
“1. Whilst the operational delivery of mental healthcare is for the relevant NHS trusts, this case raises wider concerns about the continuity of healthcare provision between custody and the community, the treatment and management of offenders with personality disorders and the support afforded to probation practitioners in working with offenders with complex mental health and substance or personality issues.”

Source location
Response from Ministry of Justice
Page 2 · response
Published 23 May 2024
Open published response
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How this respondent position was interpreted

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

PFD Monitor interpretation
HMPPS has limited levers to secure healthcare attendance at Pathfinder meetings or escalate gaps in mental health services.

Verbatim wording from the response
“35. Terrorist and terrorist-risk offenders commonly have multiple, complex needs and face difficulties in accessing services. As healthcare does not allocate treatment based on national security risk but rather on clinical need, terrorist and terrorist-risk offenders cannot be auto-prioritised. To date, HMPPS has limited levers to use to secure healthcare attendance at Pathfinder and escalate issues where mental health services are lacking.”

Source location
Response from Ministry of Justice
Page 10 · response
Published 23 May 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
Employing more psychological practitioners in prisons is not possible because of current budget constraints.

Verbatim wording from the response
“MPFT would welcome the opportunity to employ more psychological practitioners in prisons, however given the constraints of our current budgets this is not possible. Close partner relationships with individual establishments enable us to take an active part in Health Needs Assessments and, where indicated, to work with NHS England to develop business case submissions to request additional funding for psychological provision in addition to the actions already taken above.”

Source location
Response from Midlands Partnership NHS
Page 2 · response
Published 23 May 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
Oxford Health NHS Foundation Trust is required to provide assurance about current practices and psychological services at Bullingdon and Huntercombe prisons.

Verbatim wording from the response
“My regional colleagues in the South East have also been asked to engage with BHFT on the concerns raised, and with OHFT who, as set out above, are now providing the secondary mental health services to HMPs’ Bullingdon and Huntercombe. We note that OHFT are required to provide assurance of current practices at these two prisons, including the current position on the level of available psychological services against the background of the previous failure by MPFT to provide these to the perpetrator of the attack whilst he was in prison. We will carefully consider the Trusts’ responses, once sighted on these.”

Source location
Response from NHS England
Page 4 · response
Published 23 May 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
Psychological provision at HMP Huntercombe cannot currently be increased because staffing posts remain unfilled pending a commissioners’ decision on the proposed staffing model.

Verbatim wording from the response
“At HMP Huntercombe the current staffing model is one WTE band 4 assistant psychologist and 0.3 WTE band 8a psychologist. The service has not been able to fill these posts and a business case was submitted by the service to commissioners that proposed three alternatives to the staffing model. The purpose of the business case is to give us the best chance to recruit into posts, to increase the provision for psychology and to expand the service which can be offered. The business case has been submitted and we hope to receive a decision in July 2024. There are high levels of trauma within the establishment and the focus will be to treat the trauma and any associated symptoms.”

Source location
Response from Oxford Health
Page 2 · response
Published 23 May 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Inability of prison healthcare provision to fully meet mental health patients’ needs

Inability to provide compulsory medication and treatment in prison

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

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

Concerns raised1

Insufficient mental health team capacity for women awaiting assessment or inpatient beds

Concerns raised1

Failure to provide adequate secondary mental healthcare in prison

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.14

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6

Actions described in response 2

Respondent positions 1

Actions described in response 14

Respondent positions 6