Recurring concern

Failure to reliably reconcile mental-health and medication history in prison healthcare

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First reported 19 May 2016•Latest report 20 Sep 2022

Definition

What this concern includes

Includes prison-healthcare processes for obtaining, checking, reconciling, referring and clinically acting on relevant mental-health history, prior antidepressant or other medication use, and discrepancies between information disclosed on arrival and community healthcare records.

Not included

Excludes general prison healthcare access, treatment or prescribing failures where no deficiency in obtaining, reconciling or considering prior mental-health or medication history is identified.
Excludes generic prison information-sharing or record-keeping failures without a material prior mental-health or medication-history context.
Excludes failures to act after relevant history has been reliably obtained and considered, unless the history-reconciliation process itself was also deficient.
Excludes unrelated prison risk information, custody records and medication-security concerns that do not concern prior mental-health or medication history.

Reports: 2
Individual concerns: 3
Date range: 2016–2022
Stated actions: 4

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.

Care UK1

Government Legal Department1

Hewell Prison1

HM Prison and Probation Service1

London Ambulance Service NHS Trust1

Pentonville Prison1

Practice Plus Group1

Prisons and Probation Ombudsman1

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.

20 Sep2022
Worcestershire
Concerns raised1
1. Failure to routinely follow up discrepancies between disclosed mental health history and community GP records
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
  Implement GP2GP transfer of community GP records into HMP Hewell’s healthcare system.
  Stated by Practice Plus GroupStated completed
2. Action
  Introduce Version 4 of the Early Days in Custody pathway and passport as a systematic healthcare induction checklist.
  Stated by Practice Plus GroupStated completed
3. Action
  Implement Day 5 Senior Nurse management review and keyword searches of GP records for undisclosed suicide, self-harm or mental-health history.
  Stated by Practice Plus GroupStated completed
1. Action
  Introduce follow-up discussions for identified discrepancies, including suicide and self-harm questions, mental-health referrals where indicated, and corresponding clinical records.
  Stated by Practice Plus GroupStated completed
AI-generated summary

Gary McDonald · 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

Gary McDonald was found deceased in his cell at HMP Hewell after spending nearly four months on remand awaiting trial; the inquest concluded that he died as a result of suicide. The principal concern was that, despite prison healthcare receiving records showing a history of depression and two previous overdoses, including one seven months earlier, there was no system to follow up discrepancies between a prisoner's disclosed mental health history and community GP records.

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 routinely follow up discrepancies between disclosed mental health history and community GP records
Wider context from the report
“5) I am concerned that there is currently no system in place at HMP Hewell to follow up with a prisoner any discrepancy between the mental health history which he has disclosed on arrival at the prison, and that revealed in his community GP records. Experience suggests that a prisoner with a recorded history of mental health issues, particularly one which includes a recent episode of attempted suicide or self-harm through overdose, may be at his most vulnerable during his first days and weeks at a prison, and having been reluctant to disclose such issues for any number of reasons ( e.g. fear, embarrassment ), may be reassured to be told that healthcare staff at the prison are aware of that history and can provide confidential support. In my view, without routine follow-up in such cases, there remains a significant risk that a prisoner’s recent significant history of suicide or self-harm may be overlooked in those important early days and weeks in prison, and that such prisoners will therefore be at an increased risk of further episodes of attempted suicide during that period. ”
Source location
Gary McDonald · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement GP2GP transfer of community GP records into HMP Hewell’s healthcare system.

Verbatim wording from the response
“As part of a national NHS England rollout programme since April 2022, the Healthcare team and patients alike at HMP Hewell have benefitted from the introduction of the SystmOne upgrades commonly referred to as GP2GP. GP2GP is a process whereby the entire patient’s record from the community GP is transferred into HMP Hewell, where in effect the Healthcare team becomes the patient’s registered GP practice. The GP2GP functionality supports a number of benefits including:”

Source location
Response Practice Plus Group
Page 2 · response
Published 6 October 2022
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 Version 4 of the Early Days in Custody pathway and passport as a systematic healthcare induction checklist.

Verbatim wording from the response
“Since the Inquest, the Head of Healthcare has consulted with other stakeholders within the team about the concern raised and have considered ways this concern can be alleviated. The healthcare team have introduced an updated version (V4) of the EDiC pathway and passport. This “passport” is a document that serves as a checklist to be completed by the healthcare induction team. By working through such a checklist in a systematic way, assurance is gained that all identified needs are being met for all patients, and to a consistent standard.”

Source location
Response Practice Plus Group
Page 3 · response
Published 6 October 2022
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
Implement Day 5 Senior Nurse management review and keyword searches of GP records for undisclosed suicide, self-harm or mental-health history.

Verbatim wording from the response
“The key change between the previous version and Version 4 of this EDiC pathway is the timing of the Initial Management Review. It has been moved from Day 3 to Day 5 and now includes key word searches for suicide/self-harm references and will be undertaken after the GP2GP transition process has been completed. This key word search of the GP records has been implemented to identify any discrepancies in the information that the patient has disclosed during the reception screenings. If a patient was to deny a history of mental health illness during the reception screenings, the key word search would pick this history up in his GP records.”

Source location
Response Practice Plus Group
Page 3 · response
Published 6 October 2022
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 follow-up discussions for identified discrepancies, including suicide and self-harm questions, mental-health referrals where indicated, and corresponding clinical records.

Verbatim wording from the response
“At the point where the Day 5 management check has been completed, we have introduced new measures such as the key word search that address those specific concerns raised by the Coroner. These measures enable identification of previously undisclosed information and discrepancies about previous suicidal ideation and/or self-harm (irrespective of when). If any discrepancy is identified a member of the EDiC team (either a nurse or HCA) will return to meet the patient, informing him of our findings and then proceed to ask him 2 specific questions:”

Source location
Response Practice Plus Group
Page 3 · response
Published 6 October 2022
Open published response
19 May2016
Inner North London
Concerns raised2
1. Failure to refer antidepressant history to a prison GP
2. Failure to recognise prior compliant antidepressant treatment
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.
Respondent positions 1
1. Position
  BEH-MHT is responsible for concerns relating to its mental health services and will provide the relevant response and action plan.
  Stated by Care UKRedirects responsibility
AI-generated summary

Samuel Rodney Darren BLAIR · 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

Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison 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
Failure to refer antidepressant history to a prison GP
Wider context from the report
“4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression. Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration. The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this. Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville. ”
Source location
Samuel Rodney Darren BLAIR · Prevention of Future Deaths report
Page 3 · 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 recognise prior compliant antidepressant treatment
Wider context from the report
“4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression. Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration. The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this. Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville. ”
Source location
Samuel Rodney Darren BLAIR · Prevention of Future Deaths report
Page 3 · 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
BEH-MHT is responsible for concerns relating to its mental health services and will provide the relevant response and action plan.

Verbatim wording from the response
“Response: We refer to the response provided by BEH-MHT and we will collaborate with them to ensure that the action plan outlined in their response is implemented and that all healthcare staff are aware of the plan.”

Source location
2016-0196-Response-by-Care-Uk
Page 1 · response
Published 19 May 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to routinely follow up discrepancies between disclosed mental health history and community GP 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.4

Concerns raised2

Failure to refer antidepressant history to a prison GP

Failure to recognise prior compliant antidepressant treatment

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

Actions described in response 4

Respondent positions 1