11 Jan 2024 Nicholas CORK · Prevention of Future Deaths report Inner North London
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Concerns raised 4
Lack of consistent criteria for welfare checks and their recording View source Failure to undertake required welfare checks at least every 24 hours View source Inadequacy of the welfare-check recording system View source
Failure to investigate and implement improvements to welfare-check systems View source See 1 more concern
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sapphire Independent Housing
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
Sapphire Independent Housing
Reinforce policy and procedure guidance through team meetings, away days, online training, refresher training and an accessible policy library.
View source
Sapphire Independent Housing
Draft and submit a standalone At Risk policy for Board approval and wider publication.
View source
Sapphire Independent Housing
Formulate and use a written contractor induction package covering the conduct and recording of welfare checks.
View source
Sapphire Independent Housing
Extend night-shift hours and use a mandatory handover template to communicate failed welfare checks and At Risk issues between shifts.
View source
Sapphire Independent Housing
Deliver and continue welfare-check, risk-management, complex-needs and related At Risk training for resident-facing and Conway House staff.
View source
Sapphire Independent Housing
Introduce and monthly monitor At Risk procedure performance indicators through operational management meetings, with senior management review and Board reporting of incidents and KPI failures.
View source
Sapphire Independent Housing
Introduce a shift leader on every shift to oversee At Risk compliance and effective handover.
View source
Sapphire Independent Housing
Recruit permanent night staff with job descriptions incorporating the At Risk procedure.
View source
Sapphire Independent Housing
Implement smaller, more frequent working patterns instead of seven consecutive shifts to reduce fatigue and missed checks.
View source
Sapphire Independent Housing
Review the welfare-check spreadsheet every Friday and recruit an administration assistant to provide qualitative oversight and sample testing.
View source See 7 more actions
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AI-generated summary
Nicholas CORK · 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
Nicholas Cork lived in supported accommodation and was found unresponsive in his room in the early morning of 22 May 2023; paramedics verified his death at 06:28. The report raised concerns that required welfare checks were not completed for at least 36–48 hours before his death, including a missed opportunity when staff opened his door but did not enter or properly assess him. It also identified concerns about inconsistent recording practices, the adequacy of the spreadsheet system, and staff training and follow-up.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of consistent criteria for welfare checks and their recording
Wider context from the report “(1) There was evidence that staff at Conway House were significantly concerned for Mr Cork’s welfare, which is why he was deemed as ‘at risk’. As a result of being ‘at risk’ I was told that welfare checks were required to be undertaken, at least every 24 hours. Such checks required a staff member to physically see and interact with Mr Cork or, in the alternative, to telephone him and speak to him. Welfare checks were then required to be recorded on a spreadsheet. Despite this, I was told in evidence that welfare checks would only be recorded if the resident in question was actually ‘seen’ by the staff member undertaking the check; this raises the concern that there is disparity about what constitutes a welfare check and what will or will not be recorded .
” Source location Nicholas CORK · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to undertake required welfare checks at least every 24 hours
Wider context from the report “(2) I heard evidence that prior to Mr Cork being found unresponsive in his room on 22 May 2023, the last recorded welfare check for Mr Cork was during the early shift of Saturday 20 May 2023. The concern here is that Mr Cork, despite being required to have welfare checks at least once every 24 hours, was not properly checked upon for between 36-48 hours prior to his death .
” Source location Nicholas CORK · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequacy of the welfare-check recording system
Wider context from the report “(4) In evidence, I was taken through the spreadsheet that is used to record all checks and/or welfare checks required for any residents of Conway House. The record system appears to have been a basic Microsoft Excel spreadsheet devised by staff. I was told that the computer and/or spreadsheet often ‘crashed’, which led to data sometimes not being able to be recorded . I also observed that some fields of the spreadsheet were often left blank . Staff undertaking and recording checks regularly appeared not to input their name(s) or the time at which checks were undertaken . I was also told that while there was some training on how to undertake and record welfare checks, this was not needed because it was a simple task.
The concern here is that the recording system for welfare checks may not be adequate and that the approach taken to filling in the data required on the spreadsheet varied from one staff member to another, which may also indicate that there is a training need.
” Source location Nicholas CORK · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to investigate and implement improvements to welfare-check systems
Wider context from the report “(5) I was told in evidence that the same spreadsheet is still used to record any checks and/or welfare checks required for residents. I was told that the issues identified with a lack of checks for Mr Cork were caused by the fact that there were a significant number of agency staff on duty and that Conway House no longer uses agency staff. However, the staff member that opened Mr Cork’s door at 20:35 (without entering the room or seeing Mr Cork) on 21 May 2023 and subsequently found him unresponsive on the morning of 22 May 2023 was a substantive member of staff.
I was not reassured that any proper investigation into these issues had been undertaken or that any action(s) required to bring about improvements in the system of undertaking and recording welfare checks have been identified and/or implemented .
” Source location Nicholas CORK · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce policy and procedure guidance through team meetings, away days, online training, refresher training and an accessible policy library.
Verbatim wording from the response “Since October 2023, there has been greater focus on revisiting the guidance derived from policies and procedures to support day to day practice; not just at induction but on a continuing basis, through team meetings, team away days, and a wider organisational approach. The At Risk procedure, while well-established as a precursor to the Missing Persons policy, has not historically been set out fully in a written policy document. A standalone policy document is in the process of being drafted and is expected to be presented to the Sapphire Board in May, for wider publication in June 2024. All staff receive online training in policies and procedures with periodic refresher training. There is also an easily accessible online hub where a policy library is available.” Source location Response from Devonshires
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Draft and submit a standalone At Risk policy for Board approval and wider publication.
Verbatim wording from the response “Since October 2023, there has been greater focus on revisiting the guidance derived from policies and procedures to support day to day practice; not just at induction but on a continuing basis, through team meetings, team away days, and a wider organisational approach. The At Risk procedure, while well-established as a precursor to the Missing Persons policy, has not historically been set out fully in a written policy document. A standalone policy document is in the process of being drafted and is expected to be presented to the Sapphire Board in May, for wider publication in June 2024. All staff receive online training in policies and procedures with periodic refresher training. There is also an easily accessible online hub where a policy library is available.” Source location Response from Devonshires
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formulate and use a written contractor induction package covering the conduct and recording of welfare checks.
Verbatim wording from the response “████████ was not a substantive member of staff but, it is accepted, had worked at Conway House as a member of agency staff for a prolonged period. Sapphire continue to use agency staff at Conway House. However, there have been material improvements in how this is managed and how the processes to be followed are communicated; in particular a thorough written contractor induction package has been formulated, which focuses both on the conduct of welfare checks and their recording.” Source location Response from Devonshires
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend night-shift hours and use a mandatory handover template to communicate failed welfare checks and At Risk issues between shifts.
Verbatim wording from the response “In particular, the handover process has been reviewed to place further emphasis on the At Risk procedure. This review was completed on 8th August 2023. There has, as a result, been an increase in the working hours of night shift workers, thereby extending the handover period between shifts to ensure an appropriate face to face interaction to discuss any incidents that have occurred. There is an expectation that any failed welfare checks, or any problems with the At Risk procedure, will be highlighted at this handover. There is a” Source location Response from Devonshires
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver and continue welfare-check, risk-management, complex-needs and related At Risk training for resident-facing and Conway House staff.
Verbatim wording from the response “Further training provision has also been (and continues to be) implemented in relation to the At Risk procedure with a view to offering staff an increased level of support and knowledge. Training in complex needs, dual diagnosis and personality disorder was delivered by Homeless Link on 22nd September 2023 for all resident-facing colleagues. A workshop covering welfare checks and risk management was attended by all Conway House staff in February 2024. Following a Homeless Link recommendation that Sapphire services are reflective of psychologically informed environment approaches, as these environments naturally reduce the levels of incidents and are more conducive to positive residential operations, the Camden Commissioning team are providing training in this area and regular refresher courses to all staff in Pathways.” Source location Response from Devonshires
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce and monthly monitor At Risk procedure performance indicators through operational management meetings, with senior management review and Board reporting of incidents and KPI failures.
Verbatim wording from the response “Sapphire has recognised that there needs to be a greater level of management review of the At Risk procedure, and greater accountability for proper checks being carried out. The Homeless Link report noted that if the completion of the At Risk checks was a process for which managers were forensically held to account by the Executive Team and reviewed at Board level, culturally the missing of checks would be far less likely to happen, whatever the chaotic dynamic of the service. This culture of accountability has been implemented through, for example, a housing operations team away day in April 2024, which focused on discussing Key Performance Indicators (KPIs), including in relation to the operation of the At Risk procedure, which are to be introduced and monitored monthly as part of the Operational Management meeting.” Source location Response from Devonshires
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a shift leader on every shift to oversee At Risk compliance and effective handover.
Verbatim wording from the response “It has been recognised that the weekend is the lowest level of staffing at Conway House due to the nature of the funding, rota and management working pattern. The Homeless Link report suggested that consideration be given to whether there should be management checks taking place at these times, for example, the organisational on-call system could incorporate a management check of the At Risk register during the weekend with a view to tightening the safety net of checks so that they are not missed. A shift leader position has now been introduced for each shift, tasked (in part) with ensuring that the At Risk procedure has been complied with and that an effective handover is completed with the next shift.” Source location Response from Devonshires
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit permanent night staff with job descriptions incorporating the At Risk procedure.
Verbatim wording from the response “Permanent night staff have been recruited by Sapphire (with a start date of the end of April 2024) with a specific job description that incorporates the At Risk procedure, which should increase continuity of knowledge and experience across the staffing body.” Source location Response from Devonshires
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement smaller, more frequent working patterns instead of seven consecutive shifts to reduce fatigue and missed checks.
Verbatim wording from the response “In September 2023, Sapphire completed a review of working shift patterns and how the removal of a ‘7 days in a row’ shift pattern and its replacement with a more balanced working pattern may mean staff are more refreshed and less prone to burnout (which could have lead to an increased risk of missed checks). Smaller more frequent working patterns have been implemented across the board.” Source location Response from Devonshires
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the welfare-check spreadsheet every Friday and recruit an administration assistant to provide qualitative oversight and sample testing.
Verbatim wording from the response “Serious consideration has been given to an alternative method of recording welfare checks but, following a thorough review, it has been decided to maintain the current format, with which staff are familiar, and which has functionality to record all the required information relevant to welfare checks. The additional focus on training, management oversight and accountability that has been a feature of revisions to the At Risk process as a whole, equally applies to the record-keeping of the welfare checks on the spreadsheet and should ensure operational improvement. The spreadsheet is currently reviewed by a manager every Friday. Additionally, a recruitment process is underway for a new administration assistant to assist with housing management tasks, which will include the oversight of the spreadsheet with qualitative checks and sample testing.” Source location Response from Devonshires
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing At Risk procedure remains fit for purpose and provides adequate welfare checks and escalation mechanisms when correctly followed.
Verbatim wording from the response “Sapphire considers that this policy, if understood and followed correctly, properly provides for the welfare checking of the vulnerable persons within its care and includes appropriate mechanisms for failed safety checks to result in an escalation of checks and, if necessary, the triggering of the missing persons procedure.” Source location Response from Devonshires
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing spreadsheet is considered adequate for recording welfare checks, so its format will be maintained rather than replaced.
Verbatim wording from the response “At the time of May 2023, the spreadsheet used to record welfare checks was considered to be adequate, insofar as it allowed for the timing of the check, the identification of who had completed it and any additional comments to be recorded. It is recognised that its use was dependent on the computer that stores it being functional, but technical issues were extremely rare and there was a manual workaround about which staff were fully informed. Any manual records were promptly recorded on the digital spreadsheet.” Source location Response from Devonshires
Open published response
13 Nov 2023 Igor Kacper SZALAPSKI · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Lack of policy on when to increase welfare checks View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Depaul UK
Implement an organisational welfare-check procedure defining routine and increased checks, authorisation, duration and recording requirements.
View source
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AI-generated summary
Igor Kacper SZALAPSKI · 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
Igor hanged himself in his room at a hostel for homeless young people on 30 April 2023. Concerns included failures to re-contact the crisis team after staff found him drowsy and incoherent, insufficient meaningful staff contact and welfare checks, inadequate engagement with partner agencies and family contact, a lack of self-harm and suicide awareness training, and a chaotic hostel culture.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of policy on when to increase welfare checks
Wider context from the report “However, I have read the report since. It went into some detail and identified that, when Igor was found at 6.25pm, no staff member had undertaken a welfare check of him since half past midnight, whereas there should have been at least one per shift. I was told at inquest that staff were disciplined about this after Igor’s death.
At the time of Igor’s death, there was no national policy on when to increase welfare checks . I was told that there is now national guidance.
” Source location Igor Kacper SZALAPSKI · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an organisational welfare-check procedure defining routine and increased checks, authorisation, duration and recording requirements.
Verbatim wording from the response “3.2.7 Concern 7:
“At the time of Igor’s death, there was no national policy on when to increase welfare checks. I was told that there is now national guidance.”” Source location Response from DePaul
Open published response
Concerns raised 1
Lack of written instructions for conducting welfare checks View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Jamie Lee Bennett · 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
Jamie Lee Bennett, who had been abstinent from drugs and methadone for approximately eight months, was found unresponsive in his room at Norfolk Park Bail Hostel on 2 May 2020 and was pronounced deceased by paramedics. The report identified concerns about incomplete sharing of his substance-misuse and Naloxone information, reduced support after release, unclear responsibilities and inadequate training and auditing for welfare checks, and a delay in calling emergency services.
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 written instructions for conducting welfare checks
Wider context from the report “The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued
There are no written instructions on how to conduct welfare checks . There is no audit process in place to ensure staff are conducting welfare checks appropriately
It is my opinion there is a risk that future deaths may occur unless there are:
• Clear, written instructions on how to conduct welfare checks
• Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff
• An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately
” Source location Jamie Lee Bennett · Prevention of Future Deaths report
Open source report
7 Apr 2022 Nicholas Tom Rose · Prevention of Future Deaths report Dorset
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Concerns raised 1
Failure to require an appropriate verbal response during welfare checks View source
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AI-generated summary
Nicholas Tom Rose · 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
Nicholas Tom Rose, a serving prisoner at HMP Guys Marsh, was found deceased in his cell on 19 May 2019 after consuming “Spice”, with the medical cause of death involving airway obstruction and aspiration of gastric content. The report raised concern that accepting a “grunt” as a verbal response during a welfare check may provide insufficient information to assess a prisoner's welfare and could contribute to future deaths if the practice continued.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to require an appropriate verbal response during welfare checks
Wider context from the report “i. I am concerned that accepting a “grunt” as a verbal response to a welfare check does not fulfil the requirement as set out in the Notice to Prison Officers mentioned above. Such a response gives very limited information upon which a prison officer can assess a prisoner’s welfare . Accepting such a response potentially loses sight of the purpose of a welfare check, which must be to check that the prisoner is alive, immediately safe and well; that is, that they are conscious, breathing, not in a state of distress, not in a state of intoxication and that there are not any other factors that might require immediate intervention to prevent harm. A verbal response to a welfare check allows a prison officer to assess if a prisoner has responded in an appropriate manner, giving an indication as to whether the prisoner retains the cognitive function to provide an appropriate response. A “grunt” does not allow such an assessment . Therefore, I have a concern that future deaths could occur if accepting such a response remains the accepted practice .
” Source location Nicholas Tom Rose · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish reminders requiring verbal welfare-check responses and cell access when no response is obtained.
Verbatim wording from the response “I understand that evidence was given at the inquest that HMP Guys Marsh’s local arrangement is that staff must receive a verbal response from prisoners during welfare checks and unlock, and that notices to staff and prisoners have been issued setting out this requirement. I have received assurance from the Governing Governor that further notices to staff and prisoners were published in May 2022, following the inquest, to serve as a reminder of the expectations during welfare checks that a verbal response must be obtained, not a grunt, and that if a verbal response is not obtained then staff must access the cell to check on the welfare of the prisoner.” Source location Response from HM Prison and Probation Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct and record daily compliance observations of welfare checks, with monthly assurance review and performance-management challenge for failures.
Verbatim wording from the response “Notices to staff and prisoners will now be re-published regularly and compliance checks are carried out by wing Custodial Managers (CMs) who observe officers unlocking prisoners to ensure that welfare checks are being carried out correctly, and this is recorded each day in wing diaries. A review of the assurance checks is carried out on a monthly basis by the Head of Residence and any” Source location Response from HM Prison and Probation Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train new prison officers to conduct roll-check, unlock and welfare checks, emphasising confirmation of prisoner safety and welfare.
Verbatim wording from the response “Prison officers undertaking initial training (currently known as New Officer Apprentices) are trained to conduct checks and the training emphasises the requirement for officers to confirm the safety and welfare of prisoners during roll checks, unlocks, and welfare checks.” Source location Response from HM Prison and Probation Service
Open published response
22 Oct 2021 Anthony John Larcher · Prevention of Future Deaths report Dorset
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Concerns raised 1
Lack of observations and welfare checks for prisoners found under the influence of psychoactive substances View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Anthony John Larcher · 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
On 21 March 2018, Anthony John Larcher, a serving prisoner at HMP Guys Marsh, was found in his cell. The report identifies concerns about monitoring prisoners under the influence of psychoactive substances, the lack of round-the-clock healthcare, healthcare involvement in ACCT reviews, the accessibility of medical information, and the reception of prisoners arriving in large cohorts.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of observations and welfare checks for prisoners found under the influence of psychoactive substances
Wider context from the report “i. There could be future deaths across the prison estate nationally due to a lack of observations and welfare checks upon prisoners who are found under the influence of Spice and I request consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of their Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP) and the Custodial Officer Intermediate Life Support initiative (COILS).
” Source location Anthony John Larcher · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Gather information from regional prison safety groups about local initiatives for observations and welfare checks.
Verbatim wording from the response “The first concern you raise is that there could be future deaths across the prison estate due to a lack of observations and welfare checks on prisoners who are found under the influence of illicit psychoactive substances, and you have requested that consideration be given to a national roll out of some of the local initiatives which have been implemented at HMP Guys Marsh. The national Drug Strategy Team have been in touch with regional prison safety groups to gather information on the local initiatives which have been implemented around the country, including those in place at HMP Guys Marsh, and are in talks with NHSE/I national team about rolling out some of these initiatives on a national scale. We are committed to learning from local practices and to use these to inform the development of national policies to drive improvement and work to save lives and keep people safe.” Source location 2021-0356-Response-from-HMPPS_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss nationally rolling out local drug-related safety initiatives with the NHSE/I national team.
Verbatim wording from the response “The first concern you raise is that there could be future deaths across the prison estate due to a lack of observations and welfare checks on prisoners who are found under the influence of illicit psychoactive substances, and you have requested that consideration be given to a national roll out of some of the local initiatives which have been implemented at HMP Guys Marsh. The national Drug Strategy Team have been in touch with regional prison safety groups to gather information on the local initiatives which have been implemented around the country, including those in place at HMP Guys Marsh, and are in talks with NHSE/I national team about rolling out some of these initiatives on a national scale. We are committed to learning from local practices and to use these to inform the development of national policies to drive improvement and work to save lives and keep people safe.” Source location 2021-0356-Response-from-HMPPS_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation HMPPS is responsible for deciding whether local welfare, substance intervention and life-support processes should be rolled out nationally.
Verbatim wording from the response “1. Consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP), and the Custodial Officer Intermediate Life Support initiatives (COILS).” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Matters of concern i, ii, iii and v do not relate to NHS Digital, so it has no comment on them.
Verbatim wording from the response “We do not consider that matters of concern i, ii, iii or v relate to NHS Digital and thus have no comment on these.” Source location 2021-0356-Response-from-NHS-Digital_Published
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16 Jul 2021 Miss Joanna Daly · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Absence of specific guidance for conducting welfare checks in the First Night Centre View source
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AI-generated summary
Miss Joanna Daly · 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
Miss Joanna Daly was found unresponsive in her cell at HMP New Hall on the morning of 2 June 2019, and her death was confirmed. The inquest jury found that healthcare checks in the First Night Centre had not been carried out adequately and that this could have contributed to her death. The report raises concern about the absence of specific guidance for welfare checks of vulnerable prisoners in the First Night Centre.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of specific guidance for conducting welfare checks in the First Night Centre
Wider context from the report “During the course of the Inquest, the matter of checks undertaken by healthcare staff on prisoners resident for their first night in the prison's First Night Centre was heard in evidence. The jury found that no guidance as to how such checks were to be conducted had been provided to the staff undertaking the checks , and that it was possible that this contributed to Joanna's death.
Since Joanna's death, checks within HMP New Hall have been undertaken whereby welfare checks undertaken at the First Night Centre are now completed by prison staff. The new arrangements have been in place since October 2020.
Whilst evidence was provided of the key times at which such checks are undertaken, it became apparent that there was no specific guidance provided to prison staff to explain what was required to be undertaken during a welfare check . The particular vulnerability of prisoners resident on the First Night Centre is the reason for such checks.
I am concerned about the absence of any specific guidance , in view of the findings of the jury in relation to the night checks that were previously undertaken by the healthcare staff at the time of Joanna's death.
This could impact upon the quality of the welfare checks that are now undertaken by the prison staff, in the context of the First Night Centre where prisoners may be particularly vulnerable. I am under a duty to report this matter upon consideration of the evidence as provided to the court.
” Source location Miss Joanna Daly · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement revised welfare-check processes requiring resident responses, specifying timing and requirements, and recording night-state checks in the electronic custody system.
Verbatim wording from the response “Since Ms Daly’s death, HMP New Hall has introduced new processes to improve the quality of welfare checks. In July 2021, a notice to staff was issued covering First Night Centre welfare checks during night state – most easily described to those not familiar with the term as the time during the night whereby all people in custody are residing within their cells and no activity occurs out of cell. The notice revised previous instructions and clarified that staff must now obtain a response from a resident in the First Night Centre. The notice details the times welfare checks should take place, the purpose of the welfare check and what is required from a welfare check. It also reminds staff to create a record summary for all those in custody during the night state on the National Offender Management Information System (an electronic record of all individuals in custody).” Source location 2021-0245-Response-from-HMPPS_Published
Open published response
Concerns raised 1
Failure to conduct welfare checks during first morning cell unlocks View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Brett Anthony Marrs · 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
Brett Anthony Marrs, a long-term drug user, was found collapsed in his prison cell after morning unlock on 4 September 2018. The inquest concluded that he died as a result of synthetic cannabinoid and morphine toxicity. Concerns included inadequate first-aid and resuscitation training for prison officers and failures to conduct welfare checks during morning cell unlocks.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to conduct welfare checks during first morning cell unlocks
Wider context from the report “2. CCTV footage viewed at the inquest showed a prison officer conducting a first morning cell unlock on C wing without conducting even the most basic of welfare checks and this despite clear notices from management drawing to the attention of staff the necessity of carrying out welfare checks, particularly at the time of the first morning unlock. Evidence was heard to the effect that this was not an isolated instance . Given that notices and reminders appear not to have achieved uniform observance , you are asked to consider how better compliance with welfare checks can be achieved.
” Source location Brett Anthony Marrs · Prevention of Future Deaths report
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20 Nov 2019 Mr Gary Leyland · Prevention of Future Deaths report Manchester North
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Concerns raised 2
Failure to update handover information about expected welfare checks View source Failure to maintain complete and reliable welfare-check records View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mr Gary Leyland · 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 Gary Leyland was found deceased in his supported accommodation on 13 November 2019 after taking excessive prescribed medication, with the inquest conclusion recording suicide and morphine toxicity. Concerns included failures to contact medical or mental health services after suicidal thoughts were disclosed, poor documentation and handover information, the use of security staff for welfare checks without clear evidence of training, and the absence of an updated risk assessment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to update handover information about expected welfare checks
Wider context from the report “2. Only the handover sheets for the 7th and 8th November were updated to advise staff to “keep an eye” on Mr Leyland. NO updates were on the handover sheets for the 9-12th November despite the evidence being welfare checks would still have been expected on these dates. It is therefore unclear how security staff working the 10th and 11th November (weekend) would have been able to expect to check on Mr Leyland.
” Source location Mr Gary Leyland · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain complete and reliable welfare-check records
Wider context from the report “1. Documentation and Recording of Information - during the course of the Inquest the Court was provided with and taken to various documents and records relating to Mr Leyland. The Court found the recording and documentation to be of a poor quality and standard. The chronology document was not complete, information as to when Mr Leyland had been seen was missing. The observational log was completed in some instances with the use of an X as opposed to the staff members initials so it was not clear if he had been seen and if so by whom.
” Source location Mr Gary Leyland · Prevention of Future Deaths report
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21 Sep 2019 Ricky Barcock · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 1
Client wellbeing checks protocol failing to establish appropriate physical checks and rousing when necessary View source
Linked response
UK Addiction Treatment Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
UK Addiction Treatment Group
Update the Observation and Client Wellbeing Checks Policy with expanded explanations and explicit working-practice instructions.
View source
UK Addiction Treatment Group
Review related risk assessments, policies and procedures to ensure they operate collectively with the updated checks policy.
View source
UK Addiction Treatment Group
Provide all staff with further training on the updated policy and safe, effective working practice.
View source
UK Addiction Treatment Group
Adapt registered-manager monitoring of working practice to reflect the reviewed and updated checks policy.
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AI-generated summary
Ricky Barcock · 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
Ricky Barcock was admitted to a recovery centre for detoxification and rehabilitation and was later found unresponsive in his room after sleeping for several hours. He was found to have died from morphine toxicity, with methadone and diazepam use also recorded. The principal concern was whether resident wellbeing checks should include regular physical checks and rousing clients when necessary.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Client wellbeing checks protocol failing to establish appropriate physical checks and rousing when necessary
Wider context from the report “To further review the client wellbeing checks protocol of September 2018 in order to consider the appropriateness of making physical checks and rousing client’s when necessary in order to check on their wellbeing
” Source location Ricky Barcock · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Observation and Client Wellbeing Checks Policy with expanded explanations and explicit working-practice instructions.
Verbatim wording from the response “Following receiving your letter and report dated 24th October 2019, Oasis Bradford has reviewed and updated the Observation and Client Wellbeing Checks Policy December 2019 (previously the Client Wellbeing Checks Protocol September 2018). Please find a copy of this policy enclosed. The policy has been expanded in explanation and explicit instruction on working practice.” Source location 2019-0462-Response-from-Oasis-Recovery-Communities
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review related risk assessments, policies and procedures to ensure they operate collectively with the updated checks policy.
Verbatim wording from the response “In addition the related risk assessments, policy and procedures have also been visited to ensure they work collectively together. A list of the related risk assessments, policy and procedures can be seen at the end of the Observation and Client Wellbeing Checks Policy December 2019.” Source location 2019-0462-Response-from-Oasis-Recovery-Communities
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide all staff with further training on the updated policy and safe, effective working practice.
Verbatim wording from the response “All staffs have been trained in the Client Wellbeing Checks Protocol Sept 2018. Following the review and update of the Observation and Client Wellbeing Checks Policy December 2019 all staffs are now to receive further training to ensure working practice is safe and effective and in line with the policy changes. This will be complete in January 2020.” Source location 2019-0462-Response-from-Oasis-Recovery-Communities
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adapt registered-manager monitoring of working practice to reflect the reviewed and updated checks policy.
Verbatim wording from the response “The ongoing monitoring and management of safe and effective working practice will be conducted by the registered manager at Oasis Bradford through working practice observation, supervision, handovers and team meetings. This is already in place and will be adapted to reflect the reviewed and updated the Observation and Client Wellbeing Checks Policy December 2019.” Source location 2019-0462-Response-from-Oasis-Recovery-Communities
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10 Jan 2019 Christopher Michael SEAL · Prevention of Future Deaths report Avon
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Concerns raised 1
Absence of a welfare-check policy for primary care View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Christopher Michael SEAL · 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 Michael Seal died by suicide on 30 November 2017 at playing fields at Bath Spa University, having been found suspended from rugby posts. In the five days before his death, he was assessed as high risk by mental health services, but concerns included underestimation of his condition, failures to escalate after missed contact and a police welfare check, inadequate information sharing with his family, and weaknesses in records, policies and staff processes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of a welfare-check policy for primary care
Wider context from the report “6. I was told that there is no “welfare check policy” for those in primary care ; that the policy which exists is for secondary or tertiary care and is therefore not applicable to the service users or staff in primary care . I was told that Avon and Somerset Constabulary are in the process of writing a “welfare check policy” and it may be beneficial for there to be liaison with the police forces in the AWP area to ensure that any new policy that you consider is appropriate is in line with their expectations as to what a police officer can and will do following such a call. This would also raise the question of training.
” Source location Christopher Michael SEAL · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request close liaison and joint working with Avon and Somerset Police on welfare checks.
Verbatim wording from the response “AWP have contacted Avon and Somerset Police to request close liaison and joint working regarding their ‘Welfare Check Policy’ to ensure understanding and expectations are aligned. The local representative for the Avon & Somerset Crisis Concordat will maintain close follow” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The police are responsible for the welfare-check policy, while the Trust will liaise and work jointly with them.
Verbatim wording from the response “No “welfare check policy” for those in primary care” Source location 2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.