Recurring concern

Unreliable court-to-prison transfer information

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First reported 25 Oct 2016•Latest report 21 Oct 2021

Definition

What this concern includes

Includes failures in the dedicated court-to-prison transfer of information about defendants or prisoners who will be received by, returned to or managed in prison, including court lists, custody records, offence circumstances, mental-health concerns, vulnerability, suicidal intent and other safety-relevant court information, together with failures to communicate or confirm receipt of that information.

Not included

  • Excludes prison-to-court transfer information, court attendance preparation and information sent from prisons to courts unless the assertion also concerns the court-to-prison direction.
  • Excludes generic inter-agency information-sharing failures without a court-to-receiving-prison context.
  • Excludes failures in mental-health assessment, custody observation or ACCT operation after relevant court information has been reliably transferred.
  • Excludes court administrative information that has no identified relevance to prisoner safety or receiving-prison decisions.
Reports
4

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2016–2021

First to latest report issue date

Stated actions
7

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Dac Beachcroft LLP1
David Ake & Co1
Department of Health and Social Care1
Hampshire County Council1
HCRG Care Ltd1
HM Courts & Tribunals Service1
HM Prison and Probation Service1
HM Prison Service1
Home Office1
Mental Health Act assessors1
Ministry of Justice1
Northamptonshire 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.

  1. West Yorkshire Eastern

    AI-generated summary

    Richard Gordon Franks · 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

    Richard Gordon Franks was remanded in custody at HMP Leeds and was found dead in his cell on 12 April 2019, after appearing distressed and indicating that he was likely to commit suicide if sentenced to imprisonment. The concerns included that this information was not communicated to prison staff, that he mistakenly believed he had received a five-year sentence, and that no checks were made on him for approximately 10 hours.

    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 communicate suicide risk and relevant court information to prison staff

    Wider context from the report

    “(1) Mr Franks had a known history of self-harming and suicide attempts. His emotional state when seen at court on 11 April 2019 was triggered at least in part to his reaction to a development in the prosecution brought against him which he had not foreseen. His statement that he was likely to commit suicide was not communicated to either the security staff at the court or the prison staff. In consequence, the prison staff had no information concerning the events which took place at court. (2) Mr Franks somehow perceived that he had been sentenced to five years imprisonment, which was not the case. This false impression caused him to be in distress prior to being locked in his cell around 19:00 hours. (3) Had information concerning his emotions at court been relayed to the prison staff, this may have triggered a decision to open an ACCT – the process by which a prisoner is subject to increased monitoring and support. In the event no checks were made on him for some 10 hours. (4) At a previous hearing on 25.02.17 Mr Franks had made a comparable threat to kill himself as a result of what he perceived to be an adverse development in the case brought against him. At that time his signed consent authorising information to be passed to the prison was obtained and communicated to the prison. (5) The benefit of relaying helpful information to the prison intended to protect Mr Franks, does not seem to involve a breach of professional privilege. It would have been sufficient to request that the prison staff assess Mr Franks for themselves on his return in view of (unspecified) developments at court that day. ”

    Source location

    Richard Gordon Franks · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remind appropriate organisations whenever a client repeats a threat of self-harm.

    Verbatim wording from the response

    “We accept there are lessons to be learned. We have always endeavoured to follow the correct protocol when threats of self-harm are made by clients. However, we will ensure that we remind appropriate organisations each time a threat to self-harm is repeated.”

    Source location

    2021-0355-Response-from-David-Ake-Co-Solicitors_Published
    Page 2 · response
    Published 22 October 2021

    Open published response
  2. Hampshire

    AI-generated summary

    Trevor Albert Oakley · 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

    Trevor Albert Oakley was found hanging from a bedsheet ligature in his prison cell on 22 October 2018, shortly before he was due to start his trial. The inquest concluded that his death was suicide. The principal concern was that night staff were not immediately informed which prisoners were due in court the following morning, meaning increased self-harm risks might not be identified.

    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 identify increased self-harm risk in prisoners due in Court the following morning

    Wider context from the report

    “(1) I was told that the Courts will supply the Prison with a list of prisoners who are required for trial the following day, (“the List”). The List is circulated within the prison by the OMU (Offender Management Unit) and the relevant staff should receive the List to enable them to know which particular prisoners need to be unlocked for Court attendances the following day. I was told that the Night Orderly Officer will brief the night shift officers on the wings as to what is due to be happening over the course of the night shift, but it was the evidence of more than one Prison Officer on duty that there was no notification of the prisoners due in Court the next morning. The stance adopted within the prison appeared to be that the information was available if a Prison Officer wanted to go and look for it within the system. (2) I am concerned that within the Prison it is not immediately apparent to the night staff who is due in Court the following morning from this, it flows, that any increased risk of self-harm by such prisoner(s) is not identified. ”

    Source location

    Trevor Albert Oakley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Milton Keynes

    AI-generated summary

    Jason Basalat · 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

    Jason Basalat was arrested after grabbing the steering wheel of a bus, causing it to crash into road barriers, and was remanded to HMP Woodhill. He was found hanging in his cell the following day and later pronounced dead at hospital. Concerns included inadequate sharing of information about his behaviour and mental state with the prison, and the lack of a mental health assessment or appropriate placement consideration before his transfer.

    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 of the court to inform the prison about a defendant's mental illness and related problems

    Wider context from the report

    “(1) The deceased had been arrested for Dangerous Driving when, on the 9th December 2016, he tried to grab the steering wheel of a bus travelling on the M1 motorway forcing it to collide with the barriers in the roadworks. Whilst in police custody the deceased was behaving in a bizarre manner and was assessed by a medical practitioner at the custody centre. When eventually transferred to Woodhill Prison after appearing on a Saturday Morning at Wellingborough Magistrates Court the warrant simply stated that the offence was “Dangerous Driving.” Which did not in any way give a true picture of the offence and very little information was provided to the prison as to his behaviour or mental state. The prison informed me that it would have been helpful for them to receive a copy of the deceased’s custody record that gave the full picture. (2) When the deceased appeared before the magistrates his solicitor was informed that it was not possible on a Saturday morning for a mental health assessment to be conducted. The court did not attempt to contact the prison to inform the prison of the problems being experienced by him due to his mental illness. Consideration should have been given as to the most appropriate place for the deceased to be held or to receive a mental health assessment. (3) There needs to be an urgent review by both the Northamptonshire Police and the Northamptonshire Magistrates Court as to their procedures for sharing information with the prison when it is known in advance that the prison will receive a vulnerable prisoner. ”

    Source location

    Jason Basalat · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide the prison with sufficient information about a vulnerable prisoner's behaviour, mental state and custody circumstances

    Wider context from the report

    “(1) The deceased had been arrested for Dangerous Driving when, on the 9th December 2016, he tried to grab the steering wheel of a bus travelling on the M1 motorway forcing it to collide with the barriers in the roadworks. Whilst in police custody the deceased was behaving in a bizarre manner and was assessed by a medical practitioner at the custody centre. When eventually transferred to Woodhill Prison after appearing on a Saturday Morning at Wellingborough Magistrates Court the warrant simply stated that the offence was “Dangerous Driving.” Which did not in any way give a true picture of the offence and very little information was provided to the prison as to his behaviour or mental state. The prison informed me that it would have been helpful for them to receive a copy of the deceased’s custody record that gave the full picture. (2) When the deceased appeared before the magistrates his solicitor was informed that it was not possible on a Saturday morning for a mental health assessment to be conducted. The court did not attempt to contact the prison to inform the prison of the problems being experienced by him due to his mental illness. Consideration should have been given as to the most appropriate place for the deceased to be held or to receive a mental health assessment. (3) There needs to be an urgent review by both the Northamptonshire Police and the Northamptonshire Magistrates Court as to their procedures for sharing information with the prison when it is known in advance that the prison will receive a vulnerable prisoner. ”

    Source location

    Jason Basalat · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remind custody officers and staff to follow guidance on completing Person Escort Records and attaching relevant documentation.

    Verbatim wording from the response

    “4.16 However, the Chief Constable confirms that Custody officers and staff have been reminded of the guidance in relation to the completion of PER forms and in respect of ensuring any relevant additional documentation accompanies them.”

    Source location

    2017-0423-Response-by-Northampton-Police
    Page 8 · response
    Published 27 February 2018

    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

    Contact the national police lead on custody to suggest reviewing the Person Escort form against Authorised Professional Practice guidance.

    Verbatim wording from the response

    “4.17 Further, contact will be made with the national police lead on Custody to suggest a review of the PER form to ensure it reflects the guidance in the Authorised Professional Practice.”

    Source location

    2017-0423-Response-by-Northampton-Police
    Page 8 · response
    Published 27 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Issue the liaison team’s information leaflet to legal advisers and remind them to forward CPN1 forms or endorse warrants and attach available MG5s.

    Verbatim wording from the response

    “43. Legal advisers have been issued with the above Team’s information leaflet and reminded of the need to forward the CPN1 form to the relevant custodial establishment if a vulnerable adult is remanded into custody. Failing this, to endorse the warrant and forward the MG5, if available.”

    Source location

    BASALAT-Response
    Page 5 · response
    Published 27 February 2018

    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

    Liaise with criminal justice partners to review CPN procedures and consider information forwarded to prisons when vulnerable adults are remanded.

    Verbatim wording from the response

    “42. The court will liaise with the Criminal Justice Liaison and Diversion Team, to review the robustness of the present CPN procedures and consider what further information should be forwarded to a prison should a vulnerable adult be remanded to it.”

    Source location

    BASALAT-Response
    Page 5 · response
    Published 27 February 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The concern about Magistrates’ Court procedure falls outside the matters addressed in this response.

    Verbatim wording from the response

    “2.1.2 Point (2) appears to relate solely to the procedure before the Magistrates’ Court and is not addressed in this response.”

    Source location

    2017-0423-Response-by-Northampton-Police
    Page 2 · response
    Published 27 February 2018

    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

    Additional mental-health assessment was not considered necessary because the police mental-health team cleared attendance and the CPN identified no concerns.

    Verbatim wording from the response

    “24. In any event, on this occasion, the court was advised that Mr Basalat had been given the all clear by the police doctor/mental health team to attend court. There were no concerns about Mr Basalat from the Community Psychiatric Nurse who had assessed him in custody.”

    Source location

    BASALAT-Response
    Page 4 · response
    Published 27 February 2018

    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

    Direct prison contact and prisoner risk assessment are not functions of the court, unlike those of a custodian.

    Verbatim wording from the response

    “28. It is not normal practice for a legal adviser to directly contact any prison establishment. Unlike any custodian of a detained person the court does not undertake a risk assessment of a prisoner. The police had completed a Person Escort Record form and this would have accompanied Mr Basalat.”

    Source location

    BASALAT-Response
    Page 4 · response
    Published 27 February 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The format of the Warrant of Remand is not a police matter, so no comment is made on it.

    Verbatim wording from the response

    “4.6 The format of the Warrant of Remand is not a matter for the police and the Chief Constable makes no comment on that issue.”

    Source location

    2017-0423-Response-by-Northampton-Police
    Page 6 · response
    Published 27 February 2018

    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

    A custody record is intended to document treatment in police custody, not provide a full picture of the investigation, evidence or detainee’s circumstances.

    Verbatim wording from the response

    “4.7 The Custody Record is a document which the police are required to maintain to record certain decisions made pursuant to section 37 of the Police and Criminal Evidence Act 1984 and paragraph 2.1 of Code of Practice C referred to above.”

    Source location

    2017-0423-Response-by-Northampton-Police
    Page 6 · response
    Published 27 February 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The existing Person Escort Form and round-the-clock switchboard provided sufficient risk information and a route for receiving staff to seek clarification.

    Verbatim wording from the response

    “The PER form provides staff transporting and receiving detainees with all necessary information. This includes any risks or vulnerabilities that the person may present.”

    Source location

    2017-0423-Response-by-Northampton-Police
    Page 7 · response
    Published 27 February 2018

    Open published response
  4. Inner South London

    AI-generated summary

    Richard Walsh · 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

    Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of an agreed system for transferring health care information from police stations or courts to prisons

    Wider context from the report

    “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility. ”

    Source location

    Richard Walsh · 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

    Provide AMHP guidance on confidential information sharing with GP practices and prison healthcare.

    Verbatim wording from the response

    “The Coroner report has highlighted the need for a national process for information sharing in view of the role, in this case, of general practice and/ or prison healthcare.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 3 · response
    Published 26 February 2017

    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

    Work with NHS providers and Hampshire Constabulary to review information sharing after joint police-custody assessments.

    Verbatim wording from the response

    “3.2 Sharing AMHP reports with Police”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 3 · response
    Published 26 February 2017

    Open published response
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Data last updated 7 September 2026