24 Apr 2026 Kenneth John Morris · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 2
Failure to provide required one-to-one nursing care View source Critically stretched healthcare resources View source
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AI-generated summary
Kenneth John Morris · 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
Kenneth John Morris, aged 78, died at Hull Royal Infirmary on 10 December 2025 after a second unwitnessed ward fall caused intracranial haemorrhage, brain damage and early post-traumatic epilepsy. The principal concern was that he did not receive required one-to-one nursing care because of understaffing and more pressing cases, and evidence indicated that similar deaths may occur while resources remain critically stretched.
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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 provide required one-to-one nursing care
Wider context from the report “This gentleman should have received one to one nursing care but due to a combination of understaffing and more pressing cases on the ward, he did not receive such care . Evidence was heard that had he received such care he would not have fallen and died. Evidence was also heard that within the Hull Trust and probably throughout the NHS, resources are critically stretched and whilst improvements are being proposed, I believe that the current situation makes it probable that similar deaths will occur.
” Source location Kenneth John Morris · 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 Critically stretched healthcare resources
Wider context from the report “This gentleman should have received one to one nursing care but due to a combination of understaffing and more pressing cases on the ward, he did not receive such care. Evidence was heard that had he received such care he would not have fallen and died. Evidence was also heard that within the Hull Trust and probably throughout the NHS, resources are critically stretched and whilst improvements are being proposed, I believe that the current situation makes it probable that similar deaths will occur .
” Source location Kenneth John Morris · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a new 10 Year Workforce Plan to support appropriate NHS staffing and workforce distribution.
Verbatim wording from the response “In our 10 Year Health Plan we committed to publishing a new 10 Year Workforce Plan. The plan, which will be published this year, will help ensure the NHS has the right people in the right places to deliver the best care for patients.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS trusts and employers are responsible for determining staffing levels and workforce composition.
Verbatim wording from the response “I have carefully considered the situation. Individual NHS Trusts and other employers are responsible for determining staffing levels and workforce composition. They are best placed to understand their services and the needs of their patients in order to deliver safe and effective care. I would expect Hull University Teaching Hospitals NHS Trust and all other NHS Trusts to ensure that their staffing arrangements, are appropriate following the tragic death of Mr Morris.” Source location Response from Department of Health and Social Care
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7 Apr 2026 Mark Robert Smith · Prevention of Future Deaths report Inner South London
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Concerns raised 9
Failure to ensure truthful observation records View source Failure to maintain QEH staff awareness of the limits of prison healthcare View source Failure to coordinate prison discharge through an MDT and relevant prison healthcare liaison View source
Failure to prescribe and administer medication at the correct dose View source Failure to ensure safe and clearly understood medication-system operation View source Failure to record the cell-entry escalation process in policy View source Failure to maintain prison and healthcare staff awareness of the cell-entry escalation process View source Failure to complete required patient observations View source Unavailability of larger disabled cells adapted for constant watch View source See 6 more concerns
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Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mark Robert Smith · 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
Mark Robert Smith, who was detained at HMP Thameside, died after an epileptic seizure led to cardiac arrest. The report describes concerns about medication prescribing and administration, hospital-to-prison discharge and communication, access to his cell, observation arrangements and records, staffing, and the lack of equipment for resuscitation.
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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 ensure truthful observation records
Wider context from the report “(5) I am concerned there were numerous missed and falsified observation entries in Mark’s case and how similar incidents can be prevented given the reliance on handwritten sheets being scanned onto the system at a later stage . I appreciate the efforts made with training and audits. (Practice Plus Group)
” Source location Mark Robert Smith · 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 QEH staff awareness of the limits of prison healthcare
Wider context from the report “(2) I remain concerned a similar situation could arise as did in Mark’s case regarding a discharge back to prison from QEH without an MDT meeting despite repeated requests from prison healthcare and there could be a risk to life. I note PFD evidence provided regarding improved liaison between QEH and the prison GP but note no reference to liaison between QEH and the head of the healthcare in prison, who visited QEH twice in Mark’s case.
Further, as recently as 2025 an incident occurred when there was a lack of understanding at QEH around the limited provision in healthcare in prison . I am concerned as to how awareness of the limits of prison healthcare will be disseminated on a continuing basis to new and locum staff at QEH . (QEH and Practice Plus Group)
” Source location Mark Robert Smith · 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 coordinate prison discharge through an MDT and relevant prison healthcare liaison
Wider context from the report “(2) I remain concerned a similar situation could arise as did in Mark’s case regarding a discharge back to prison from QEH without an MDT meeting despite repeated requests from prison healthcare and there could be a risk to life. I note PFD evidence provided regarding improved liaison between QEH and the prison GP but note no reference to liaison between QEH and the head of the healthcare in prison , who visited QEH twice in Mark’s case.
Further, as recently as 2025 an incident occurred when there was a lack of understanding at QEH around the limited provision in healthcare in prison. I am concerned as to how awareness of the limits of prison healthcare will be disseminated on a continuing basis to new and locum staff at QEH. (QEH and Practice Plus Group)
” Source location Mark Robert Smith · 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 prescribe and administer medication at the correct dose
Wider context from the report “(1) The wrong dose of medication could be prescribed and/or administered with life threatening consequences. Albeit I have seen evidence of significant improvements in prescribing practice at HMP Thameside since 2019 (e.g HMIP report February 2026); as recently as 2024 to 2025 HMIP and IMB reports noted “significant risks with management of medicines” and “prescribing errors.” Whilst recent internal audits in 2025 show significant improvements, medication incidents (datix) are recorded in late 2025 and the principal pharmacist notes a very busy site with multiple prescriptions screened daily.
Further, during the inquest it proved difficult to establish how Systm 1 (the medical note system) operated and whether there were risks inherent in the system itself. For example, it was suggested the system would convert mg into ml or pre-populate entries such as 100ml, in contradiction to the subsequent PFD evidence provided. (Practice Plus Group)
” Source location Mark Robert Smith · 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 ensure safe and clearly understood medication-system operation
Wider context from the report “(1) The wrong dose of medication could be prescribed and/or administered with life threatening consequences. Albeit I have seen evidence of significant improvements in prescribing practice at HMP Thameside since 2019 (e.g HMIP report February 2026); as recently as 2024 to 2025 HMIP and IMB reports noted “significant risks with management of medicines” and “prescribing errors.” Whilst recent internal audits in 2025 show significant improvements, medication incidents (datix) are recorded in late 2025 and the principal pharmacist notes a very busy site with multiple prescriptions screened daily.
Further, during the inquest it proved difficult to establish how Systm 1 (the medical note system) operated and whether there were risks inherent in the system itself . For example, it was suggested the system would convert mg into ml or pre-populate entries such as 100ml , in contradiction to the subsequent PFD evidence provided. (Practice Plus Group)
” Source location Mark Robert Smith · 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 record the cell-entry escalation process in policy
Wider context from the report “(3) Healthcare staff may be unable to enter a prisoner’s cell at night and monitor them in a situation which may not constitute a “medical emergency” but in which a patient nevertheless requires attention; a patient could decline and the situation become life threatening. I have received detail from Serco of “an escalation process” if Oscar 1 and Hotel 1 cannot agree about entry to a cell and I have been told this has been “recommunicated” to all staff. However, this is not recorded in a policy. I am concerned about awareness of the process for all prison and healthcare staff including on an ongoing basis. (Serco and Practice Plus Group).
” Source location Mark Robert Smith · 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 prison and healthcare staff awareness of the cell-entry escalation process
Wider context from the report “(3) Healthcare staff may be unable to enter a prisoner’s cell at night and monitor them in a situation which may not constitute a “medical emergency” but in which a patient nevertheless requires attention; a patient could decline and the situation become life threatening. I have received detail from Serco of “an escalation process” if Oscar 1 and Hotel 1 cannot agree about entry to a cell and I have been told this has been “recommunicated” to all staff. However, this is not recorded in a policy. I am concerned about awareness of the process for all prison and healthcare staff including on an ongoing basis. (Serco and Practice Plus Group).
” Source location Mark Robert Smith · 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 complete required patient observations
Wider context from the report “(5) I am concerned there were numerous missed and falsified observation entries in Mark’s case and how similar incidents can be prevented given the reliance on handwritten sheets being scanned onto the system at a later stage. I appreciate the efforts made with training and audits. (Practice Plus Group)
” Source location Mark Robert Smith · 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 Unavailability of larger disabled cells adapted for constant watch
Wider context from the report “(4) There are no larger disabled cells (which can accommodate hospital beds and wheelchairs) adapted to also facilitate a constant watch. Security concerns, in this might not be possible, and a similar situation might occur to that in Mark’s case. (HMPPS)
” Source location Mark Robert Smith · Prevention of Future Deaths report
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24 Mar 2026 James Scott COATES · Prevention of Future Deaths report Cumbria
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Concerns raised 2
Insufficiently robust arrangements for ensuring that drivers with serious conditions have their licences properly reviewed View source Failure of drivers to self-report potentially significant conditions to the DVLA View source
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AI-generated summary
James Scott COATES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Scott Coates died after a head-on collision while driving around a bend at approximately 90 mph on an unlit rural road, where 75% of the Cats Eye reflectors were not functioning. He sustained unsurvivable injuries and was declared dead at the roadside. The principal concern was that drivers with potentially significant conditions, including epilepsy and cannabis use, may not notify the DVLA, while legislation places the reporting responsibility on licence holders rather than doctors, which was considered insufficiently robust to ensure proper licence review.
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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 Insufficiently robust arrangements for ensuring that drivers with serious conditions have their licences properly reviewed
Wider context from the report “I previously sent you a Prevention of Future Deaths Report (in relation to the deaths of Neil Errington and Gareth and Patricia Evans) highlighting my concern that the expectation that drivers would self-report their conditions (which arises as a matter of legislation) was not being followed.
The evidence in this inquest provides further cause for concern. Once again, the evidence is that a person with potentially significant conditions never notified the DVLA, and that his doctors did not draw it to the DVLA's attention because legislation places the onus on licence holders and not their doctors . I remain of the view that this is insufficiently robust to ensure that drivers with serious conditions are not having their licences properly reviewed .
” Source location James Scott COATES · 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 of drivers to self-report potentially significant conditions to the DVLA
Wider context from the report “I previously sent you a Prevention of Future Deaths Report (in relation to the deaths of Neil Errington and Gareth and Patricia Evans) highlighting my concern that the expectation that drivers would self-report their conditions (which arises as a matter of legislation) was not being followed .
The evidence in this inquest provides further cause for concern. Once again, the evidence is that a person with potentially significant conditions never notified the DVLA , and that his doctors did not draw it to the DVLA's attention because legislation places the onus on licence holders and not their doctors. I remain of the view that this is insufficiently robust to ensure that drivers with serious conditions are not having their licences properly reviewed.
” Source location James Scott COATES · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver educational sessions for healthcare professionals encouraging direct DVLA notifications when patients cannot or will not notify themselves.
Verbatim wording from the response “I can confirm that the DVLA is engaging with healthcare professionals and has delivered a series of educational sessions to encourage clinicians to notify the DVLA directly where a patient is unable or unwilling to do so themselves. Further engagement with regulatory bodies, clinical networks and healthcare professionals will continue to better understand any concerns or issues that may be preventing notifications being made to the DVLA by doctors and driving licence holders.” Source location Response from Department for Transport
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engagement with regulatory bodies, clinical networks and healthcare professionals to identify barriers to DVLA notifications.
Verbatim wording from the response “I can confirm that the DVLA is engaging with healthcare professionals and has delivered a series of educational sessions to encourage clinicians to notify the DVLA directly where a patient is unable or unwilling to do so themselves. Further engagement with regulatory bodies, clinical networks and healthcare professionals will continue to better understand any concerns or issues that may be preventing notifications being made to the DVLA by doctors and driving licence holders.” Source location Response from Department for Transport
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise public awareness of the legal duty to notify the DVLA about medical conditions and the consequences of non-notification.
Verbatim wording from the response “The actions being taken by my Department and the DVLA to address the issues raised in this Prevention of Future Deaths Report include reviewing the self-declaration forms for notifying the DVLA of a medical condition, raising public awareness of the legal duty to notify medical conditions to the DVLA and the consequences of not doing so and reinforcing the existing General Medical Council guidance which advises doctors when to notify the DVLA where a patient continues to drive despite being advised to notify the DVLA.” Source location Response from Department for Transport
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce existing General Medical Council guidance on notifying the DVLA when patients continue driving despite advice to notify.
Verbatim wording from the response “The actions being taken by my Department and the DVLA to address the issues raised in this Prevention of Future Deaths Report include reviewing the self-declaration forms for notifying the DVLA of a medical condition, raising public awareness of the legal duty to notify medical conditions to the DVLA and the consequences of not doing so and reinforcing the existing General Medical Council guidance which advises doctors when to notify the DVLA where a patient continues to drive despite being advised to notify the DVLA.” Source location Response from Department for Transport
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and improve self-declaration forms and associated notification processes.
Verbatim wording from the response “The actions being taken by my Department and the DVLA to address the issues raised in this Prevention of Future Deaths Report include reviewing the self-declaration forms for notifying the DVLA of a medical condition, raising public awareness of the legal duty to notify medical conditions to the DVLA and the consequences of not doing so and reinforcing the existing General Medical Council guidance which advises doctors when to notify the DVLA where a patient continues to drive despite being advised to notify the DVLA.” Source location Response from Department for Transport
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19 Mar 2026 Paul Robert Joseph NASH · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 3
Failure to convey information about critically depleted seizure medication to the GP View source Failure to prioritise prescriptions for same-day supply of critically depleted seizure medication View source Difficulties obtaining sufficient quantities of epilepsy medication for continuous access View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paul Robert Joseph NASH · 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
Paul Robert Joseph NASH, who had epilepsy secondary to HSV encephalitis, was found deceased at home on 23 October 2025 after apparently suffering a seizure during the night. He had run out of Carbamazepine and missed three doses. The concerns included that the GP surgery did not appear to be told that he had completely run out of medication and did not prioritise the prescription for same-day collection, as well as wider difficulties for epilepsy patients in obtaining sufficient medication supplies.
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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 convey information about critically depleted seizure medication to the GP
Wider context from the report “1. During the phone call with the Surgery on 21 October 2025, HEADWAY made it clear to the Surgery that the Deceased had run out of his Carbamazepine (seizure medication) completely and, although he had taken that morning's dose, if he did not receive more medication that day he would not have his evening dose or any other doses. Although HEADWAY was reassured that the GP would be notified that the Deceased had run out of his seizure medication, this fact did not appear to have been conveyed to the GP and the prescription was not prioritised to ensure he received it the same day.
” Source location Paul Robert Joseph NASH · 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 prioritise prescriptions for same-day supply of critically depleted seizure medication
Wider context from the report “1. During the phone call with the Surgery on 21 October 2025, HEADWAY made it clear to the Surgery that the Deceased had run out of his Carbamazepine (seizure medication) completely and, although he had taken that morning's dose, if he did not receive more medication that day he would not have his evening dose or any other doses. Although HEADWAY was reassured that the GP would be notified that the Deceased had run out of his seizure medication, this fact did not appear to have been conveyed to the GP and the prescription was not prioritised to ensure he received it the same day .
” Source location Paul Robert Joseph NASH · 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 Difficulties obtaining sufficient quantities of epilepsy medication for continuous access
Wider context from the report “2. The Deceased's Consultant Neurologist indicated that many epilepsy patients across the country currently experience difficulties in obtaining sufficient quantities of medication to ensure optimum seizure control i.e. it is difficult for them to obtain batch quantities to ensure they always have access to some in the event that they find they are running low or there are delays in the pharmacy processing a repeat prescription (apparently in some areas processing can take up to 10 days) .
” Source location Paul Robert Joseph NASH · Prevention of Future Deaths report
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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 formal escalation process prioritising requests for critical medicines, including same-day clinical review and urgent clinician alerts.
Verbatim wording from the response “Critical medication escalation process- the practice is introducing a formal process for identifying and escalating requests relating to critical medications including anti-epileptic medication. Where a patient reports that they have run out, or are about to run out of such medication, this will be treated as a priority medication safety issue and escalated promptly for same day review by an appropriate clinical or prescriber. Where such a task is sent to the Duty Clinician it will be flagged as urgent and an instant message will also” Source location Response from Sundon Medical Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train reception and administrative staff to recognise critical medicines, manage split-strength requests, escalate concerns and verify communications.
Verbatim wording from the response “Staff training on critical medications and escalation. Reception and administrative staff have received and will continue to receive further training on:” Source location Response from Sundon Medical Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review implementation of the medication-safety changes and monitor compliance with urgent-medicine, dosage-wording, written-request and escalation procedures.
Verbatim wording from the response “Audit and Review. The practice will undertake a review of these changes after implementation to ensure they are embedded and effective. This will include monitoring compliance with the new process for urgent critical medicines, checking the use of clear dosage wording for split-strength prescriptions and reviewing whether staff are following the written request and escalation process consistently.” Source location Response from Sundon Medical Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clearly communicate the urgent status of critical-medication prescriptions to pharmacies to support prompt dispensing.
Verbatim wording from the response “Pharmacy communication for urgent critical medication. Where a patient has run out of critical medication and an urgent prescription is issued, the practice will ensure that the urgent nature of the request is clearly highlighted with the pharmacy to support prompt dispensing.” Source location Response from Sundon Medical Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider repeat dispensing, batch prescribing, or one-off reserve prescriptions for suitable patients at risk of running out of critical medication.
Verbatim wording from the response “Repeat dispensing / batch prescribing for suitable patients. For patients prescribed long term critical medication, the practice will consider whether repeat dispensing or batch prescribing with future dated repeat prescriptions for up to six months is appropriate, particularly where patients may have memory difficulties, cognitive impairment, or other vulnerabilities that place them at risk of running out of medication. This will be assessed on a case by case basis to ensure suitability and safety. Where patients have experienced difficulty obtaining medication on time the practice will consider prescribing a one-off extra medication prescription to provide patients with a month of their time critical medication in hand.” Source location Response from Sundon Medical Centre
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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 the pharmacy sector to improve awareness of emergency supply provisions and patients’ access to emergency medicines.
Verbatim wording from the response “The Department recognises that awareness of emergency supply provisions amongst both patients and pharmacy staff can be improved. The Department is committed to working with the pharmacy sector to improve awareness and ensure patients can access emergency supplies when necessary to prevent harm or death. We are currently in consultation with the sector representative body, Community Pharmacy England, on the 2026/27 Community Pharmacy Contractual Framework. As part of this consultation we will take into account learnings from Paul Nash’s death.” Source location 2026-0161 - Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inform epilepsy patients about the Charlie Card emergency-supply self-advocacy tool.
Verbatim wording from the response “Informing Epilepsy Patients of the Charlie Card - this is a self advocacy tool designed to assist individuals with epilepsy who find themselves without their regular anti-seizure medications. It highlights the legal framework under the Human Medicines Regulations 2012, allowing patients to request an emergency supply of anti-seizure medications from any pharmacy without a prescription, provided certain conditions are met. The card serves as a reminder to pharmacists of their legal duties and aims to ensure that patients can access life- saving medications quickly and efficiently. The Charlie Card is available free through the charity shop of SUDEP Action and individuals can also download a copy.” Source location Response from Sundon Medical Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clear patient information about prescription processing and pharmacy dispensing times through the website and reception.
Verbatim wording from the response “Clear patient information regarding repeat turnaround times The practice will continue to ensure that patients are clearly informed that repeat prescriptions require a two working days for surgery processing and that pharmacies require additional time for dispensing. This information will be displayed on the website and in reception to encourage timely ordering and reduce the risk of medication running out.” Source location Response from Sundon Medical Centre
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England and delegated Integrated Care Boards commission and performance-manage general practice, including addressing persistent performance concerns.
Verbatim wording from the response “General practice is commissioned and performance-managed by NHS England, with responsibility delegated to Integrated Care Boards, who are expected to work with practices to provide support and agree improvement plans where performance concerns arise. Where issues persist, commissioners can intervene and use contractual levers, including remedial action, to ensure safe and appropriate patient care.” Source location 2026-0161 - Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing urgent-supply arrangements, including pharmacist emergency supplies and NHS 111 referrals, provide routes to obtain urgently needed medicines.
Verbatim wording from the response “The Department recognises that delays in prescriptions being sent by GPs, such as in Paul Nash’s tragic case, can result in patients being left without vital medication. Provisions are in place to prevent patients being left in this situation. If a patient needs to access an urgent supply of their medicines, then there are a range of options available, which can be found at Emergency prescriptions - NHS.” Source location 2026-0161 - Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing regulations and NHS pharmacy terms require community pharmacies to dispense NHS medicines with reasonable promptness and notify patients of delays.
Verbatim wording from the response “The Department recognises that delays in pharmacies processing repeat prescriptions can result in patients unexpectedly running out of vital medicines. That is why all community pharmacies providing dispensing services for NHS patients in England are required to dispense medicines for patients on demand with reasonable promptness. This is set out in regulations and within the terms of service for all pharmacies on the NHS Pharmaceutical list.” Source location 2026-0161 - Response from Department of Health and Social Care
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Concerns raised 8
Insufficient medication verification during care-needs assessment View source Failure to prevent administration of GP-discontinued medication View source Failure to follow up medication incidents for learning affecting vulnerable patients View source
Failure to provide complete current medication and stop-date information during care handover View source Failure to transfer all prescribed medication into the electronic MAR and cross-check it at agency handover View source Inaccurate or incomplete recording of medication administration View source Failure to liaise with the community pharmacy about regularly dispensed medication View source Risk of discontinued or essential seizure-control medication being incorrectly administered View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John Malcolm FISHER · 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
John Malcolm Fisher was admitted to hospital on 22 April 2025 with persistent focal seizures that developed into status epilepticus, and he died on 4 May 2025 after the seizures could not be controlled. The report raises concerns about inaccurate or incomplete medication information during transfers between community services and the omission of sodium valproate from the care agency’s medication record, resulting in six days without that medication.
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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 Insufficient medication verification during care-needs assessment
Wider context from the report “4) Coastal Homecare confirmed that an assessment of needs was carried out on 15 April 2025 by a supervisor attending Mr Fisher's home address. The UCR handwritten medication forms were used to digitally record the required medications into the Coastal Homecare electronic system. Initially I was told that photographs of the medication were taken as well but on checking no photographs could be recovered save one of skin creams . It is apparently not standard practice for photographs to be taken during this kind of assessment but during the inquest it was agreed this would be good practice in future to achieve greater clarity for daily carers who frequently change.
” Source location John Malcolm FISHER · 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 prevent administration of GP-discontinued medication
Wider context from the report “1) I heard evidence from Mr Fisher's GP practice (Trinity Medical Centre) that they received a letter from Brighton Urgent Community Response (UCR) team indicating that they had, in turn, received a referral from the local Adult Social Care Team requesting a package of care assessment on 8 April. This assessment was carried out on 9 April and from handwritten medication administrative records (MAR) complied by the UCR Team from Brighton hospital, support was provided to Mr Fisher until 15 April. According to the UCR records this apparently included phenobarbital tablets twice a day even though Mr Fisher's GP had discontinued the phenobarbital on 8 April 2025 . 3 liquid AEDs were also given including sodium valproate.
” Source location John Malcolm FISHER · 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 follow up medication incidents for learning affecting vulnerable patients
Wider context from the report “6) Coastal Homecare management then self-reported the incident to the local Adult Safeguarding Team and also the Care Quality Commission but at the time of the inquest there has been no follow-up by either organisation to ascertain if there are any lessons to learn for the benefit of other vulnerable patients .
” Source location John Malcolm FISHER · 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 provide complete current medication and stop-date information during care handover
Wider context from the report “3) UCR then arranged for a care agency, Coastal Homecare, to take over supporting Mr Fisher. During the inquest I saw a referral from prepared by UCR confirming that Coastal Homecare were required to assist Mr Fisher three times a day to help with his personal care and medicine administration. However, the only medication information that was supplied by the UCR team to Coastal Homecare referred to blister packs and liquid medication including antibiotics for chest infection. No further details of current regular medication, dosage, timing or form of medication (eg blister pack, separate boxes or liquids) were provided at all. In addition, the antibiotics were only for a short number of days but no clear indication is given when they were to stop and may well have finished by the time Coastal took over care.
” Source location John Malcolm FISHER · 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 transfer all prescribed medication into the electronic MAR and cross-check it at agency handover
Wider context from the report “5) Coastal Healthcare indicated that a mistake was made when documenting the medications in that although the UCR handwritten forms included sodium valproate oral solution, this was not added at all into the Coastal Homecare electronic MAR chart . As a result, Coastal Homecare accepted that between 16 April to 21 April (6 days) Mr Fisher did not receive any sodium valproate oral solution. This was one of three liquid antiepileptic drugs Mr Fisher should have received to help control possible seizures. This mistake was not spotted at all and there is no system in place to cross check what has previously been given when there is a handover between different care agencies nor was there any liaison with the community pharmacy who regularly dispensed Mr Fisher's medication.
” Source location John Malcolm FISHER · 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 Inaccurate or incomplete recording of medication administration
Wider context from the report “2) It is far from clear whether the UCR records are accurate regarding whether phenobarbital was given or not. The handwritten evidence says it was given but not whether this was from a blister pack or a separate box. Mr Fisher’s community pharmacist gave evidence that for some years he had dispensed phenobarbital in a separate box and not in a blister pack.
” Source location John Malcolm FISHER · 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 liaise with the community pharmacy about regularly dispensed medication
Wider context from the report “5) Coastal Healthcare indicated that a mistake was made when documenting the medications in that although the UCR handwritten forms included sodium valproate oral solution, this was not added at all into the Coastal Homecare electronic MAR chart. As a result, Coastal Homecare accepted that between 16 April to 21 April (6 days) Mr Fisher did not receive any sodium valproate oral solution. This was one of three liquid antiepileptic drugs Mr Fisher should have received to help control possible seizures. This mistake was not spotted at all and there is no system in place to cross check what has previously been given when there is a handover between different care agencies nor was there any liaison with the community pharmacy who regularly dispensed Mr Fisher's medication .
” Source location John Malcolm FISHER · 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 Risk of discontinued or essential seizure-control medication being incorrectly administered
Wider context from the report “Overall, after hearing evidence over two days regarding the administration of Mr Fisher's AED medication, I remain concerned that patients in the community are at risk of either being given medication that has been discontinued by a GP or not being given essential medication to control seizures .
” Source location John Malcolm FISHER · 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 Strengthen escalation pathways by referring complex medicines-reconciliation issues to senior clinicians and SCFT pharmacy support.
Verbatim wording from the response “• Clear escalation pathways have been strengthened, including referral to senior clinicians and SCFT pharmacy support for complex medicines reconciliation.” Source location Response from Sussex Community NHS Foundation Trust
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 Provide staff with Plexus shared-care-record access for real-time GP medication summaries.
Verbatim wording from the response “• Since October 2025, SCFT staff have access to shared care records via the Plexus system (which links digital care records across Sussex GP’s, hospital and community healthcare services as well as local authorities), enabling real-time access to GP medication summaries and reducing reliance on emailed or static information.” Source location Response from Sussex Community NHS Foundation Trust
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 Revise and implement UCR referral documentation to require receiving agencies to reconcile medicines with prescribers and pharmacies and clarify that UCR MAR charts are for SCFT staff only.
Verbatim wording from the response “• UCR referral documentation is being revised to clearly reinforce current agreements that receiving care agencies must undertake their own medicines reconciliation directly with the prescriber and community pharmacy.” Source location Response from Sussex Community NHS Foundation Trust
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 Strengthen referral-pathway expectations that medicines reconciliation is confirmed when care responsibility transfers.
Verbatim wording from the response “• SCFT has strengthened expectations within referral pathways that medicines reconciliation must be confirmed at transitions of care, particularly where responsibility for medicines administration is transferring.” Source location Response from Sussex Community NHS Foundation Trust
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 Embed pharmacy support within the UCR and General Virtual Ward model for complex or unclear medication regimes.
Verbatim wording from the response “• Pharmacy support is now embedded within the UCR/General Virtual Ward model, providing timely expert advice where medication regimes are complex or unclear.” Source location Response from Sussex Community NHS Foundation Trust
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 Integrate GP Connect into the digital platform and current practice to verify medicines and identify recent changes.
Verbatim wording from the response “• At the time Mr Fisher was receiving support from our service, GP Connect access was not available to our digital platform. Since October 2025, we have fully integrated GP Connect to our digital platform, and into current practice as an additional safeguard to support safer medication management and continuity of care. Subject to appropriate consent arrangements and patient opt-out rights, authorised staff are now able to review GP medication summaries to verify prescribed medicines and identify recent medication changes during referral, assessment, and handover processes. This has strengthened our ability to cross-check medication information and identify discrepancies at an early stage.” Source location Response from Coastal Homecare
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 Require staff to cross-check medicines against prescribing records, administration records, and referral documentation during handover.
Verbatim wording from the response “The following changes have now been implemented:” Source location Response from Coastal Homecare
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 Photograph all medicines present at assessment and onboarding for every new care package.
Verbatim wording from the response “The following changes have now been implemented:” Source location Response from Coastal Homecare
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 Update the MAR chart SOP with guidance on discontinued medicines remaining in patients’ homes and mandatory GP second checks for discrepancies.
Verbatim wording from the response “• The SOP is being updated to include explicit guidance on the management of recently discontinued medications that remain physically present in the home, including a mandatory second check with the GP where discrepancies arise.” Source location Response from Sussex Community NHS Foundation Trust
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 Complete a formal review of the MAR chart SOP for UCR and Home First services.
Verbatim wording from the response “Action taken and planned:” Source location Response from Sussex Community NHS Foundation Trust
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 staff briefings and training aligned with the revised MAR chart SOP after approval.
Verbatim wording from the response “• The SOP is being updated to include explicit guidance on the management of recently discontinued medications that remain physically present in the home, including a mandatory second check with the GP where discrepancies arise.” Source location Response from Sussex Community NHS Foundation Trust
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 a themed review of UCR medication incidents involving MAR charts and report findings through Trust governance structures.
Verbatim wording from the response “• A themed review of medication incidents involving MAR charts within UCR is underway to inform ongoing quality improvement, training, and assurance.” Source location Response from Sussex Community NHS Foundation Trust
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 Record each person’s dispensing pharmacy and require escalation to relevant healthcare professionals when medication discrepancies or uncertainties arise.
Verbatim wording from the response “We recognise, however, that some medication changes initiated within hospital settings, Urgent Community Response services, or other secondary care pathways may not always be immediately reflected within GP Connect records. Our revised procedures therefore also require liaison with relevant healthcare professionals, including pharmacists, and specialist teams, where appropriate, to support safe and accurate medication management.” Source location Response from Coastal Homecare
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 Require all staff to complete additional Epilepsy Awareness training.
Verbatim wording from the response “• All staff are now required to complete additional Epilepsy Awareness training as part of our ongoing commitment to strengthening knowledge, understanding, and safe practice across the service. Additionally, representatives of the organisation have attended the Local Authority’s Medication Adults: Epilepsy Awareness, Seizure Management and Buccal Midazolam training to further enhance our medication management procedures though continued learning.” Source location Response from Coastal Homecare
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 Attend Local Authority training on epilepsy awareness, seizure management, and buccal midazolam.
Verbatim wording from the response “• All staff are now required to complete additional Epilepsy Awareness training as part of our ongoing commitment to strengthening knowledge, understanding, and safe practice across the service. Additionally, representatives of the organisation have attended the Local Authority’s Medication Adults: Epilepsy Awareness, Seizure Management and Buccal Midazolam training to further enhance our medication management procedures though continued learning.” Source location Response from Coastal Homecare
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 Receiving care agencies are responsible for medicines reconciliation with prescribers and pharmacies; SCFT MAR charts are not definitive records for external providers.
Verbatim wording from the response “• UCR referral documentation is being revised to clearly reinforce current agreements that receiving care agencies must undertake their own medicines reconciliation directly with the prescriber and community pharmacy.” Source location Response from Sussex Community NHS Foundation Trust
Open published response
4 Feb 2026 Ryan Harding · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3
Failure to maintain the gate house at a security level that restricts entry of illicit materials View source Failure to maintain prison-block windows at a security level that restricts entry of illicit materials View source Delays and non-occurrence of scheduled morning welfare checks due to lack of staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ryan Harding · 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
Ryan Harding died overnight between 7 and 8 January 2023 in his prison cell after consuming drugs. Concerns included prison infrastructure and gatehouse security measures that required upgrading to reduce illicit materials entering the prison, and a delayed morning welfare check due to insufficient staffing.
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 maintain the gate house at a security level that restricts entry of illicit materials
Wider context from the report “(3) The gate house continues to require upgrading to enable enhanced security to be afforded to reduce the ability of illicit materials including drugs and mobile phones to enter the prison .
” Source location Ryan Harding · 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 maintain prison-block windows at a security level that restricts entry of illicit materials
Wider context from the report “(3) The inquest heard evidence that the windows of Alpha and Bravo blocks did in 2023 and continue to require upgrading in order to reduce the ability of illicit materials including drugs and mobile phones to enter the prison.
” Source location Ryan Harding · 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 Delays and non-occurrence of scheduled morning welfare checks due to lack of staff
Wider context from the report “(3) On the morning of 8th January 2023, the scheduled morning welfare check did not take place . The evidence of officers was that this was delayed for lack of a staff member and had been delayed on other occasions .
” Source location Ryan Harding · 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 Plan expansion works for a new Gate House and refurbishment of the existing Gate House to accommodate Enhanced Gate Security.
Verbatim wording from the response “HMP & YOI Parc is designated a Category C prison, and as such, was not originally funded or risk assessed to provide full Enhanced Gate Security. Increased and changing security challenges, including those enabled by technological advancements and changes to the make-up and nature of contraband items, have led to agreement by HMPPS that the prison should now be funded and risk assessed for Enhanced Gate Security, and the Director has, since June 2024, prioritised addressing identified requirements in Enhanced Gate Security provision.” Source location 2026-0054 - Response from HM Prison Parc
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 Use specialist screening equipment routinely to screen staff, professional visitors and social visitors entering the prison.
Verbatim wording from the response “The conventional scanning equipment which is part of the traditional Enhanced Gate Security model will be installed within the new Gate House building once it is constructed. Pending construction of the new Gate House building, G4S identified a solution to the current logistical restriction by purchasing specialist technological equipment, similar to the latest equipment used in some airports. This equipment is now routinely used to screen staff, professional visitors and social visitors coming into the prison. HMP & YOI Parc was the first prison in the UK to deploy this technology, following a review of best practice across other sectors.” Source location 2026-0054 - Response from HM Prison Parc
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 Fund and deploy additional external dog patrols to reduce contraband throwovers and support searching.
Verbatim wording from the response “Enhanced Gate Security is provided by a range of additional tools and measures which are already being used at HMP & YOI Parc. Bag scanners and handheld metal detectors are routinely used by staff to support improved searching when visitors and staff enter the prison. The Director has expanded the size of the Special Searching Team, significantly increasing the frequency and quality of searches, and there are now an average of approximately 1,700 staff entry and exit searches per month, which represents a significant increase compared with 2022. This compares favourably with the majority of establishments within the prison’s comparative prison group. G4S has funded additional external dog patrols which have worked to significantly reduce the number of throwovers experienced at HMP & YOI Parc.” Source location 2026-0054 - Response from HM Prison Parc
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 Develop a business case seeking funding for staffing and additional dogs to support searching seven days a week during core hours.
Verbatim wording from the response “The prison is currently in communication with the Authority around submission of a business case seeking funding for additional staffing to support searching seven days a week during core hours (from the time the door opens until it is secured for night state), together with additional searching dogs to support this activity.” Source location 2026-0054 - Response from HM Prison Parc
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 Expand the Special Searching Team to increase the frequency and quality of staff and visitor searches.
Verbatim wording from the response “Enhanced Gate Security is provided by a range of additional tools and measures which are already being used at HMP & YOI Parc. Bag scanners and handheld metal detectors are routinely used by staff to support improved searching when visitors and staff enter the prison. The Director has expanded the size of the Special Searching Team, significantly increasing the frequency and quality of searches, and there are now an average of approximately 1,700 staff entry and exit searches per month, which represents a significant increase compared with 2022. This compares favourably with the majority of establishments within the prison’s comparative prison group. G4S has funded additional external dog patrols which have worked to significantly reduce the number of throwovers experienced at HMP & YOI Parc.” Source location 2026-0054 - Response from HM Prison Parc
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 the phased replacement of vulnerable prison windows to reduce contraband ingress.
Verbatim wording from the response “In mid-2024, agreement was reached to move forward with a programme of window replacement works to replace the designated windows as quickly as possible, whilst maintaining the integrity of the establishment, allowing HMP & YOI Parc to remain fully operational. The significant cost of the replacement works (each replacement window unit costing in excess of £3,500) is being shared by HMPPS and G4S. A timetable for the replacement programme has been agreed with the Authority.” Source location 2026-0054 - Response from HM Prison Parc
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 Issue updated welfare-check procedures requiring physical checks during morning unlock.
Verbatim wording from the response “Following the introduction of the HMPPS framework, the HMP & YOI Parc Senior Leadership Team carefully considered measures to ensure the correct performance of enhanced roll checks and welfare checks during morning unlock resulting in a decision to align the local policy at HMP & YOI Parc with national policy set out in PSI 75/2011 and the HMPPS Framework.” Source location 2026-0054 - Response from HM Prison Parc
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 Operate enhanced daily compliance checks using CCTV review, rotational unit sampling, issue escalation and management follow-up.
Verbatim wording from the response “Following Mr Harding’s death, written instructions on correct unlock procedures and reminders of the correct process to follow when conducting welfare checks were re-issued to staff. Reminders on the correct process were also given at safety meetings. In addition, enhanced managerial checks were introduced to ensure compliance with the instructions, including daily checks being done by the prison’s Senior Managers via CCTV footage.” Source location 2026-0054 - Response from HM Prison Parc
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 Update initial and refresher training to instruct officers on positive-response welfare checks during unlock.
Verbatim wording from the response “modification to reflect a change in the timing of the welfare checks. PCOs have also received refresher training, and written and verbal instructions, confirming the correct way to conduct unlock procedures and welfare checks.” Source location 2026-0054 - Response from HM Prison Parc
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 welfare-check compliance and trends through monthly multidisciplinary Safety Meetings.
Verbatim wording from the response “Each month a multidisciplinary Safety Meeting takes place at HMP & YOI Parc at which a Safety Team Senior Manager will discuss the welfare checks completed preceding month in relation to completed quality assurance and areas where issues have been raised. This will allow in-depth discussion, understanding of any issues and identification of trends and individuals requiring further support and/or performance management. Senior Managers have been reminded by the Deputy Director of the requirement to conduct daily compliance checks.” Source location 2026-0054 - Response from HM Prison Parc
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 Reissue written instructions and reminders on correct unlock procedures and welfare checks, including communication through safety meetings.
Verbatim wording from the response “Following Mr Harding’s death, written instructions on correct unlock procedures and reminders of the correct process to follow when conducting welfare checks were re-issued to staff. Reminders on the correct process were also given at safety meetings. In addition, enhanced managerial checks were introduced to ensure compliance with the instructions, including daily checks being done by the prison’s Senior Managers via CCTV footage.” Source location 2026-0054 - Response from HM Prison Parc
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 Amend residential wing ledgers to require daily recorded welfare checks, including weekends.
Verbatim wording from the response “Officers are required to record the welfare checks in the unit ledger each day to acknowledge that all prisoners have been checked on and that they are not concerned for the prisoners’ welfare. The Residential Wing Ledger has been amended to include the following wording:” Source location 2026-0054 - Response from HM Prison Parc
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 A temporary gatehouse extension was not pursued because existing interim searching measures were considered a better use of finances, though less comprehensive.
Verbatim wording from the response “G4S previously submitted a proposal to HMPPS for a temporary extension (modular building) to accommodate Enhanced Gate Security. Understandably, this was not seen as the best use of finances since the local team had introduced interim measures to support and enhance the searching of staff and visitors, albeit not to the same level of searching achievable with Enhanced Gate Security provision. Any changes to the design of the building must be approved and funded by HMPPS.” Source location 2026-0054 - Response from HM Prison Parc
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 must approve and fund building-design changes, while G4S is contracted only to manage and maintain the existing facility.
Verbatim wording from the response “His Majesty’s Prisons & Probation Service (HMPPS) (“the Authority”) oversaw the construction of HMP & YOI Parc leading to the establishment becoming operational in 1997. Following sign-off and approval of the construction works, operational responsibility for HMP & YOI Parc was handed over by HMPPS to G4S Care & Justice Services (UK) Limited (G4S).” Source location 2026-0054 - Response from HM Prison Parc
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 Window replacement cannot be completed widescale or faster because approved suppliers, specialist contractors, prisoner relocation and security logistics constrain delivery.
Verbatim wording from the response “Practical issues dictate the speed at which window replacement works can be achieved. The windows, by their very nature and purpose, require specialist manufacture and there are a very limited number of HMPPS approved suppliers manufacturing the windows to the requisite specification. Such suppliers are in demand, not only in relation to manufacturing replacement windows for existing prisons across the nationwide prison estate, but also manufacturing windows for new establishments currently under construction.” Source location 2026-0054 - Response from HM Prison Parc
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 Welfare checks could safely be conducted by one officer, and there was no requirement for officers to conduct them in pairs.
Verbatim wording from the response “Welfare checks could, and can, safely be conducted by a single officer and there was and is no requirement for officers to conduct welfare checks in pairs.” Source location 2026-0054 - Response from HM Prison Parc
Open published response
Concerns raised 2
Lack of national pathway guidance for call handlers on assessing whether someone is breathing and whether CPR is required View source Lack of national pathway guidance for call handlers on assessing how cold the body is View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Drew John GREAVES-PIMBLETT · 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
Drew John Graves-Pimblett, aged 26 and with a history of epilepsy, was found unresponsive and not breathing at home on 22 March 2025. An ambulance was initially stood down after telephone triage, but police later commenced CPR and Drew was pronounced deceased. The inquest concluded that he died from Sudden Unexpected Death in Epilepsy (SUDEP), related to epilepsy and natural causes. The principal concern was that call handlers lacked sufficient guidance and did not ask probing questions about breathing, body temperature, turning Drew over, or stiffness before deciding that resuscitation would not be effective.
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 national pathway guidance for call handlers on assessing whether someone is breathing and whether CPR is required
Wider context from the report “Though a telephone triage is always challenging and subjective, there appears to be a gap in the national pathways for call handlers . Consideration as to further guidance and assistance to call handlers on probing questioning for fundamental aspects such as breathing and where and how to best show how cold the body is. If someone is not breathing to ask how they know and/or techniques such as head to the chest, where to take a pulse etc. for the call handler to make a more informed decision as to whether someone is breathing and if CPR is required . When a call is made to NWAS, often it is by someone not thinking straight and so specific questions on breathing and general presentation may be of assistance in assessing the call .
” Source location Drew John GREAVES-PIMBLETT · 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 Lack of national pathway guidance for call handlers on assessing how cold the body is
Wider context from the report “Though a telephone triage is always challenging and subjective, there appears to be a gap in the national pathways for call handlers . Consideration as to further guidance and assistance to call handlers on probing questioning for fundamental aspects such as breathing and where and how to best show how cold the body is . If someone is not breathing to ask how they know and/or techniques such as head to the chest, where to take a pulse etc. for the call handler to make a more informed decision as to whether someone is breathing and if CPR is required. When a call is made to NWAS, often it is by someone not thinking straight and so specific questions on breathing and general presentation may be of assistance in assessing the call.
” Source location Drew John GREAVES-PIMBLETT · 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 Provide CPR Toolkit Training to NHS Pathways health advisors, including the ‘No, No, Go’ approach and telephone-guided CPR initiation.
Verbatim wording from the response “Also, of relevance to this particular case, in terms of additional training regarding the assessment of consciousness and breathing, health advisors utilising NHS Pathways who have completed the core training are provided with ‘CPR Toolkit Training’. This encompasses what is called the ‘No, No, Go’ approach where, if the patient is not conscious or not breathing (either normally or at all), health advisors are trained to proceed immediately to the initiation of cardiopulmonary resuscitation (CPR) as presented by the system. This additional training seeks to ensure that health advisors are supported to proceed quickly to the required life supporting advice.” Source location Response from NHS England
Open published response
8 Dec 2025 OLIVER MULANGALA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5
Use of drones to deliver drugs and other contraband into prison View source Easy availability of new psychoactive substances in prison View source Easy availability of mobile phones in prison View source
Failure to hold statistics on drug-related deaths in prisons View source Failure to protect vulnerable prisoners from forced testing of illegal drugs View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
OLIVER MULANGALA · 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
Oliver Mulangala was in custody at HMP High Down, had epilepsy and a history of serious seizures, and was found dead in his cell on 13 July 2024 after suffering a drug-induced seizure. The report identifies concerns about the easy availability and use of illicit new psychoactive substances in HMP High Down, including their contribution to drug-related deaths, coercion and risks to prisoners. It also raises concerns about the availability of mobile phones and the use of drones to facilitate the delivery of drugs and other contraband into prisons.
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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 Use of drones to deliver drugs and other contraband into prison
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” Source location OLIVER MULANGALA · 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 Easy availability of new psychoactive substances in prison
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” Source location OLIVER MULANGALA · 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 Easy availability of mobile phones in prison
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” Source location OLIVER MULANGALA · 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 hold statistics on drug-related deaths in prisons
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales . Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” Source location OLIVER MULANGALA · 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 protect vulnerable prisoners from forced testing of illegal drugs
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” Source location OLIVER MULANGALA · 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 Deliver staff upskilling to improve responses to drone activity affecting prisons.
Verbatim wording from the response “We also work closely with law enforcement organisations to tackle prisons being targeted by drones. The Director General of the National Crime Agency has directed police chiefs to work with HMPPS to jointly tackle the threat of drones. For example, there are 400m restricted fly zones around all closed prisons and Young Offender Institutions. These restrictions make all unauthorised drone incursions a crime and support police and prison staff to disrupt illegal drone use. Additionally, we have developed comprehensive guidance and are delivering upskilling to staff to improve the response to drone activity impacting our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk so that we can develop and implement plans to mitigate the threat.” 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 vulnerability assessments across the prison estate to understand drone risks and inform mitigation plans.
Verbatim wording from the response “We also work closely with law enforcement organisations to tackle prisons being targeted by drones. The Director General of the National Crime Agency has directed police chiefs to work with HMPPS to jointly tackle the threat of drones. For example, there are 400m restricted fly zones around all closed prisons and Young Offender Institutions. These restrictions make all unauthorised drone incursions a crime and support police and prison staff to disrupt illegal drone use. Additionally, we have developed comprehensive guidance and are delivering upskilling to staff to improve the response to drone activity impacting our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk so that we can develop and implement plans to mitigate the threat.” 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 Invest over £40 million in physical security across 34 prisons, including anti-drone measures at more than 15 priority prisons.
Verbatim wording from the response “HMPPS is aware of the available routes for contraband, such as drugs and mobile phones, to enter prisons and how they are influenced by factors such as security measures, geographical location and prisoner cohort. Due to this, our approach to conveyance is multi-faceted. In the 2025/2026 financial year, HMPPS is investing over £40m in physical security measures across 34 prisons, including £10m on anti-drone measures, such as window replacements, external window grilles and specialist netting in over 15 priority prisons.” 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 Develop comprehensive guidance for responding to drone activity affecting prisons.
Verbatim wording from the response “We also work closely with law enforcement organisations to tackle prisons being targeted by drones. The Director General of the National Crime Agency has directed police chiefs to work with HMPPS to jointly tackle the threat of drones. For example, there are 400m restricted fly zones around all closed prisons and Young Offender Institutions. These restrictions make all unauthorised drone incursions a crime and support police and prison staff to disrupt illegal drone use. Additionally, we have developed comprehensive guidance and are delivering upskilling to staff to improve the response to drone activity impacting our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk so that we can develop and implement plans to mitigate the threat.” 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 Provide trace-detection equipment to all public sector prisons to identify drugs on physical items.
Verbatim wording from the response “illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, 54 priority establishments have airport-style enhanced gate security to screen staff and visitors, including archway metal detectors, handheld wands, and X-ray baggage scanners.” 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 Operate X-ray body scanners in all adult male closed prisons to detect and deter internally concealed illicit items.
Verbatim wording from the response “HMPPS utilises multiple countermeasures and initiatives to tackle the conveyance of drugs and mobile phones into our prisons. For example, all adult male closed prisons are equipped with X-ray body scanners, which are used to detect and deter the internal concealment of” 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 Equip 54 priority establishments with enhanced gate security, including metal detectors and X-ray baggage scanners, to screen staff and visitors.
Verbatim wording from the response “illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, 54 priority establishments have airport-style enhanced gate security to screen staff and visitors, including archway metal detectors, handheld wands, and X-ray baggage scanners.” 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 Examine all drug-related deaths through the early learning review process and use findings and recommendations to address safety concerns.
Verbatim wording from the response “However, we do monitor such deaths closely and ensure that lessons are learned from them. All drug-related deaths are examined through our early learning review process, in which cases are reviewed by the group safety lead and the resulting report considered by the Governor, the Prison Group Director and the national Safety Group and Drug and Alcohol Group. And we study the outcomes of Prisons and Probation Ombudsman’s reports and ingests in these cases very carefully and take action to address any recommendations and matters of concern that are reported.” Source location Response from HM Prison and Probation Service
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 More definitive drug-related deaths statistics cannot currently cover later years because incomplete coroner data would reduce result quality.
Verbatim wording from the response “There is inevitably a considerable time lag before more definitive statistics of this type can be produced: the decision was taken for the 2023 publication to stop at 2019 because at the time the Coroner’s data for later years was far from complete, reducing the quality of the results. We hope to collaborate with ONS again to provide a further version of this publication in the future. We also keep the contents of our Official Statistics under continuous review, to ensure their compliance with the three pillars of the Code of Practice for Statistics; trustworthiness, quality and value.” Source location Response from HM Prison and Probation Service
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 cannot publish a specific drug-related deaths category because such cases cannot be identified accurately within required publication timescales.
Verbatim wording from the response “With regard to the reporting of deaths in custody, we publish Official Safety in Custody Statistics quarterly, but do not have a specific category of ‘drug-related’ in those statistics. For administrative and statistical purposes our classification is by apparent cause of death. This has evolved specifically to help place reliable numbers of deaths in prison custody in the public domain without undue delay, and we do not use the category of ‘drug-related’ in published statistics because it is difficult to identify such cases accurately within the timescale required for our publications.” Source location Response from HM Prison and Probation Service
Open published response
21 Oct 2025 Amber Grace Walker · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2
Failure to consistently discuss SUDEP with patients with epilepsy View source Lack of SUDEP training for doctors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Amber Grace Walker · 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
Amber Grace Walker, who had epilepsy and uncontrolled nocturnal tonic-clonic seizures, was found deceased at home on 19 April 2023. A post-mortem examination identified Sudden Unexpected Death in Epilepsy (SUDEP) as the medical cause of death. The concerns were that SUDEP and Amber’s individual risk, including the implications of declining increased medication, were not discussed with her, and that SUDEP discussions and related training for doctors were not consistent or universal.
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 consistently discuss SUDEP with patients with epilepsy
Wider context from the report “i. Doctors can be reluctant to discuss SUDEP with patients and/or presume it is a discussion that has been had at previous appointments(s) with colleagues that does not need repeating. There are tools, such as the SUDEP Action-produced “SUDEP Checklist”, that can facilitate such a discussion, but they are not used universally. The SUDEP Checklist can be used by any medical practitioner who may come into contact with a patient with epilepsy. Discussions about SUDEP ensure that patients are aware of the general risks of SUDEP, the risks that are specific to the patient and the measures that can be taken to mitigate the risk.
” Source location Amber Grace Walker · 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 Lack of SUDEP training for doctors
Wider context from the report “ii. SUDEP is not covered in the medical training of doctors , despite is being the leading cause of death in patients with a diagnosis of epilepsy. It is not only neurologists that will encounter patients with epilepsy where a discussion regarding SUDEP may be required , as demonstrated by Amber’s experience.
” Source location Amber Grace Walker · Prevention of Future Deaths report
Open source report
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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 Medical schools, royal colleges and the GMC determine and oversee medical education curricula and standards, rather than the department.
Verbatim wording from the response “In relation to the education and training of doctors, individual medical schools set their own undergraduate medical curriculum. These have to meet the standards set by the General Medical Council (GMC), which monitors and checks to make sure that the standards are maintained.” Source location Response from Department of Health and Social Care
Open published response
