Recurring concern

Failure to maintain healthcare continuity for prisoners after release

First to latest report 7 Sep 2018 — 6 Feb 2026

Reports that mention this concern: 5
Times this concern has been raised: 7
Stated actions linked to this concern: 14

What this concern includes

Includes release-planning, referral, records, appointments or medication-continuity failures specifically affecting healthcare after release from prison.

What is not included

Excludes generic mental healthcare referral failures not connected to prisoner release or post-release continuity of care.
Excludes general homelessness, housing, accommodation or social-care access problems without a direct post-release mental healthcare continuity failure.
Excludes failures occurring solely during inpatient or custodial care that do not concern release arrangements or care after release.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service2

Ministry of Justice2

College of Policing1

National Police Chiefs’ Council1

NHS Dorset Integrated Care Board1

NHS England1

Probation Service1

Stoke Heath Prison1

Stoke-on-Trent City Council1

Reports and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

6 Feb2026
Suffolk
Concerns raised1
1. Shortcomings in internal information passage concerning the release of prisoners receiving mental health care
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

HM Prison and Probation Service
Stated actions 1
1. HM Prison and Probation Service
  Operate a pilot flagging prisoners on the mental health caseload and require the discharging nurse to obtain mental health sign-off before release during service hours.
Respondent positions 1
1. HM Prison and Probation Service
  NSFT was informed by email of the planned release in timely fashion, although the prisoner was not considered to require attendance.
  Disputes the concern
AI-generated summary

Paul Christopher THOMPSON · 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 Christopher THOMPSON died on 15 July 2024 after moving onto the railway tracks at Elmswell Railway Station and lying in the path of an oncoming freight train. He had a history of suicidal ideation and had been receiving mental health care in custody. The report identified shortcomings in the internal passage of information at HMP Norwich about the release of prisoners receiving mental health care, and in the timely provision of release information to Probation Services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Shortcomings in internal information passage concerning the release of prisoners receiving mental health care
Wider context from the report
“The evidence received at Inquest indicated that inadequate arrangements existed at HMP Norwich to provide for the release of prisoners in receipt of mental health care during out of hours periods. In line with procedures in place at HMP Norwich, Mr. Thompson should have been seen by the mental health team treating him so that appropriate arrangements could be put in place for follow up care and treatment in the community. This did not occur. The mental health team treating Mr. Thompson were only made aware of the fact that he had been released when it was mentioned the following day during a general staff briefing. In addition, Mr. Thompson was not given clear information around when to report to Probation Services, nor were Probation Services advised in a timely manner of Mr. Thompson’s release. As a consequence, when Mr. Thompson presented to Durham Probation Office the day after his release (12th July 2024), staff at the Probation Office in Durham had no knowledge of him or the fact of his release. Neither the failure to properly out-process Mr. Thompson from mental health services at HMP Norwich, nor the failure to inform Probation Services in Durham of Mr. Thompson’s release made a material contribution to his death. However, I am concerned that the evidence heard at Mr. Thompson’s Inquest reveals shortcomings in the internal passage of information at HMP Norwich concerning the release of prisoners in receipt of mental health care and treatment, particularly those who have expressed recent suicidal ideation. In addition, I am concerned as to the adequacy of information passage to the Probation Service relating to the release of prisoners from custody. In another case these failures may give rise to a risk of death. ”
Source location
Paul Christopher THOMPSON · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Operate a pilot flagging prisoners on the mental health caseload and require the discharging nurse to obtain mental health sign-off before release during service hours.

Verbatim wording from the response
“A pilot initiative was agreed, and is now in operation, such that a flag on the SystmOne medical record, will be seen by the HCRG discharging nurse. That flag alerts the nurse to the fact that the prisoner being discharged is currently on the caseload of NSFT. The HCRG nurse will immediately call the NSFT duty person to the discharge unit to sign off the patient for release. This of course can only work from 0800 hrs until 1900 hrs.”

Source location
2026-0066 - Response from HMP Norwich
Page 2 · response
Published 10 February 2026
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NSFT was informed by email of the planned release in timely fashion, although the prisoner was not considered to require attendance.

Verbatim wording from the response
“However an email timed at 1633 hrs the previous afternoon had been sent to the NSFT functional mailbox. The email is attached at Annex A to this response and shows recipients as ████████ and ████████. This email, even if opened by NSFT, would not have in itself resulted in the practitioners attending the discharge unit. Paul was not at that time considered to be a priority patient requiring any level of attendance from NSFT. However they were advised in timely fashion of the fact that he was to be discharged from the Prison on that day.”

Source location
2026-0066 - Response from HMP Norwich
Page 2 · response
Published 10 February 2026
Open published response
7 Oct2025
East Riding and Hull
Concerns raised1
1. Lack of liaison between prison medical services and local psychiatric services for prisoners with ongoing psychiatric issues at release
Linked response

HMPPS – Probation Service (Yorkshire & the Humber)
Stated actions 9
1. HMPPS – Probation Service (Yorkshire & the Humber)
  Operate Regional Health & Justice Teams to improve integrated health services and liaison for people under probation supervision, including prison leavers.
2. HMPPS – Probation Service (Yorkshire & the Humber)
  Hold multidisciplinary meetings with prison, primary-care and community teams to formulate transition support for complex prisoners and people who self-harm.
3. HMPPS – Probation Service (Yorkshire & the Humber)
  Use the central Data Insights Under Supervision Team to support cross-service learning, develop liaison capability and monitor action plans arising from PPO reports.
1. HMPPS – Probation Service (Yorkshire & the Humber)
  Share learning from the death across HMPPS regions and regional Health & Justice Teams.
2. HMPPS – Probation Service (Yorkshire & the Humber)
  Review and develop liaison arrangements specifically for releases to geographically distant areas.
3. HMPPS – Probation Service (Yorkshire & the Humber)
  Hold multidisciplinary meetings with prison, primary care and community teams to formulate transition support for complex prisoners and people who self-harm.
4. HMPPS – Probation Service (Yorkshire & the Humber)
  Operate the central Deaths Under Supervision Team to support cross-service learning, improve prison-community liaison skills, and monitor implementation of action plans.
5. HMPPS – Probation Service (Yorkshire & the Humber)
  Share learning from the death across HMPPS regions and regional Health and Justice Teams.
6. HMPPS – Probation Service (Yorkshire & the Humber)
  Review and develop liaison arrangements for releases to geographically different areas, using learning from the death.
AI-generated summary

Angela Christine Thompson · 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

Angela Christine Thompson died after being struck by a taxi on 11 April 2022, following repeated attempts to place herself in the path of traffic. The report raised concern about inadequate liaison between prison medical services and community psychiatric services when people with ongoing psychiatric issues are released from custody, particularly when the prison is geographically distant from their home.

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 liaison between prison medical services and local psychiatric services for prisoners with ongoing psychiatric issues at release
Wider context from the report
“Evidence was heard that in some instances within the prison estate of England and Wales, there may be a lack of liaison in patients who have on-going psychiatric issues at the time of release from custody between the prison medical services and the psychiatric services in the area where the released prisoner lives. This was felt to be of particular concern when a person is incarcerated at a prison geographically distant from their home address. Evidence suggested that such liaison would ensure and enhance continuity of care following release from prison. ”
Source location
Angela Christine Thompson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Operate Regional Health & Justice Teams to improve integrated health services and liaison for people under probation supervision, including prison leavers.

Verbatim wording from the response
“At an operational level, within HMPPS, there are now Regional Health & Justice Teams that sit within Probation Community Integration. One of the aims of these teams is to work with NHS England, Integrated Care Boards and Heads of Service in Probation to improve integrated health services for anyone subject to Probation supervision, including prison leavers.”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Hold multidisciplinary meetings with prison, primary-care and community teams to formulate transition support for complex prisoners and people who self-harm.

Verbatim wording from the response
“Multidisciplinary meetings are regularly held in relation to complex prisoners and those who engage in self-harming behaviours, these are held with primary care, prison and community teams where appropriate to formulate avenues of support during the transition from prison to the community.”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use the central Data Insights Under Supervision Team to support cross-service learning, develop liaison capability and monitor action plans arising from PPO reports.

Verbatim wording from the response
“HMPPS has also created a central Data Insights Under Supervision Team which supports the delivery of learning across Prisons and Probation to develop confidence and skills to improve liaison between”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Share learning from the death across HMPPS regions and regional Health & Justice Teams.

Verbatim wording from the response
“It is acknowledged that a release from custody to a different geographical area is more complex and learning from the circumstances of this sad death will be shared across all HMPPS Regions to ensure liaison work can be reviewed and developed specifically to deal with this situation.”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and develop liaison arrangements specifically for releases to geographically distant areas.

Verbatim wording from the response
“It is acknowledged that a release from custody to a different geographical area is more complex and learning from the circumstances of this sad death will be shared across all HMPPS Regions to ensure liaison work can be reviewed and developed specifically to deal with this situation.”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Hold multidisciplinary meetings with prison, primary care and community teams to formulate transition support for complex prisoners and people who self-harm.

Verbatim wording from the response
“Multidisciplinary meetings are regularly held in relation to complex prisoners and those who engage in self-harming behaviours, these are held with primary care, prison and community teams where appropriate to formulate avenues of support during the transition from prison to the community.”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Operate the central Deaths Under Supervision Team to support cross-service learning, improve prison-community liaison skills, and monitor implementation of action plans.

Verbatim wording from the response
“HMPPS has also created a central Deaths Under Supervision Team which supports the delivery of learning across Prisons and Probation to develop confidence and skills to improve liaison between”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Share learning from the death across HMPPS regions and regional Health and Justice Teams.

Verbatim wording from the response
“It is acknowledged that a release from custody to a different geographical area is more complex and learning from the circumstances of this sad death will be shared across all HMPPS Regions to ensure liaison work can be reviewed and developed specifically to deal with this situation.”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and develop liaison arrangements for releases to geographically different areas, using learning from the death.

Verbatim wording from the response
“It is acknowledged that a release from custody to a different geographical area is more complex and learning from the circumstances of this sad death will be shared across all HMPPS Regions to ensure liaison work can be reviewed and developed specifically to deal with this situation.”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026
Open published response
11 Mar2025
Dorset
Concerns raised2
1. Failure of some mental healthcare trusts to accept referrals for homeless prisoners on release
2. Lack of practical national guidance for continuity of prisoners’ healthcare on release
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

NHS England
Stated actions 3
1. NHS England
  Provide RECONNECT care-after-custody support and release planning to improve continuity of care for people leaving prison.
2. NHS England
  Review and refresh the prison mental health service specification, using case learning to strengthen continuity and transfer of care.
3. NHS England
  Consider developing national pathway guidance with adult mental health services for people leaving prison.
Respondent positions 1
1. NHS England
  There are currently no plans to develop specific national pathway guidance for people leaving prison, although this may be considered longer-term.
  No action considered necessary
AI-generated summary

Marta Elena Vento · 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

Marta Elena Vento was working alone as a hotel receptionist in Bournemouth when she was fatally beaten in an unprovoked attack on 9 December 2020. The report raises concerns about the sharing of remand prisoners’ risk information with sentencing courts, continuity of mental healthcare after release from prison, risk assessment of violent offenders managed by MOSOVO units, and access to patient information through the National Record Locator.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of some mental healthcare trusts to accept referrals for homeless prisoners on release
Wider context from the report
“Evidence was given that this is not the process nationally in that some mental healthcare trusts will not accept a referral if a person is homeless. There is no national guidance about the continuity of care for prisoners upon release from prison when homeless. I am concerned that this lack of continuity of care could lead to future deaths. ”
Source location
Marta Elena Vento · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of practical national guidance for continuity of prisoners’ healthcare on release
Wider context from the report
“There is a lack of national guidance to assist all healthcare providers to ensure continuity of care for a prisoner with health care needs, whether physical or mental health needs, upon release from prison. There are national standards of care and NICE guidelines in place, however none of these provide practical guidance around the delivery of care to ensure continuity of care. ”
Source location
Marta Elena Vento · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide RECONNECT care-after-custody support and release planning to improve continuity of care for people leaving prison.

Verbatim wording from the response
“To support this approach when individuals are leaving prison, there are services in place such as RECONNECT, a non-clinical ‘care after custody’ service that seeks to improve the continuity of care of individuals with identified health needs, by working with them before they leave the secure estate. RECONNECT supports transition to community-based services, enabling the safeguarding of health gains made whilst in the secure estate, with the aim of helping to reduce inequalities and address health-related drivers of offending behaviours.”

Source location
Response from NHS England
Page 2 · response
Published 11 March 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and refresh the prison mental health service specification, using case learning to strengthen continuity and transfer of care.

Verbatim wording from the response
“While there are no plans currently to develop national pathway guidance, NHS England will be considering this in the longer-term, working with the Adult Mental Health Team to ensure services are able to fully support those leaving prison.”

Source location
Response from NHS England
Page 3 · response
Published 11 March 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Consider developing national pathway guidance with adult mental health services for people leaving prison.

Verbatim wording from the response
“At present, there is no specific national pathway guidance setting out what an individual on release can expect from their local Community Mental Health Team (CMHT). The guidance relating to the Adult Mental Health Team is generic rather than focused on the prison population.”

Source location
Response from NHS England
Page 3 · response
Published 11 March 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
There are currently no plans to develop specific national pathway guidance for people leaving prison, although this may be considered longer-term.

Verbatim wording from the response
“At present, there is no specific national pathway guidance setting out what an individual on release can expect from their local Community Mental Health Team (CMHT). The guidance relating to the Adult Mental Health Team is generic rather than focused on the prison population.”

Source location
Response from NHS England
Page 3 · response
Published 11 March 2025
Open published response
14 Apr2023
Staffordshire and Stoke on Trent
Concerns raised1
1. Failure to ensure access to GP and community mental health services for people released from prison
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Stoke-on-Trent City Council
Stated actions 1
1. Stoke-on-Trent City Council
  Work with health and social-care colleagues to link people released without accommodation to homeless healthcare, mental-health nursing and wider homelessness support services.
Respondent positions 1
1. Stoke-on-Trent City Council
  The Council cannot directly address access to GP or community mental health services because it does not commission those services.
  Outside remit
AI-generated summary

Mr Darren Clifford Docherty · Prevention of Future Deaths report

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

Report summary

Mr Darren Clifford Docherty was released from HMP Stoke Heath without accommodation and was subsequently found hanging from a tree on 10 August 2023. The report raised concern that people released from prison without accommodation may be unable to access GP and community mental health services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure access to GP and community mental health services for people released from prison
Wider context from the report
“1. That when people are released from prison they do so, on many occasions, with no accommodation. Those that need GP access and community mental health services are unable to access them in these circumstances. ”
Source location
Mr Darren Clifford Docherty · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Work with health and social-care colleagues to link people released without accommodation to homeless healthcare, mental-health nursing and wider homelessness support services.

Verbatim wording from the response
“4. We will continue to work with colleagues in health and social care to support individuals released from prison with no accommodation to access GP and community mental health services by ensuring they are aware of and linked into the existing Homeless Healthcare Service and Rough Sleeping Mental Health nurse and the wider support available through Hanley Connects, the City Council’s Homelessness Hub and the Rough Sleeper Outreach Service.”

Source location
Response from Stoke on Trent City Council
Page 6 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Council cannot directly address access to GP or community mental health services because it does not commission those services.

Verbatim wording from the response
“Whilst the local authority does not commission GP or community mental health services and is therefore not in a position to directly address these concerns, it is aware that homelessness should not be a barrier to registration with a GP.”

Source location
Response from Stoke on Trent City Council
Page 3 · response
Published 29 April 2024
Open published response
7 Sep2018
West Yorkshire Eastern
Concerns raised2
1. Failure to arrange immediate GP registration after release
2. Failure to establish appropriate support services before release
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Scott Patrick Carton · 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

Scott Patrick Carton was released from prison on 5 January 2017 to the Westgate Project Hostel in Wakefield and was found dead there on 10 January 2017. His death involved the synergistic combination of prescribed methadone, pregabalin and tramadol. Concerns included the suitability of his hostel placement, the lack of anticipated psychological support and a clear management plan, and wider gaps in support for prisoners with mental health and drug dependence issues before and after release.

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 arrange immediate GP registration after release
Wider context from the report
“6. To maximise the prospect of a successful reintegration into society, prisoners with mental health issues and/or drug dependence need appropriate support services to be in place prior to their release and arrangements made to have them registered with a GP immediately (so as to provide a conduit to community mental health services) ”
Source location
Scott Patrick Carton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to establish appropriate support services before release
Wider context from the report
“6. To maximise the prospect of a successful reintegration into society, prisoners with mental health issues and/or drug dependence need appropriate support services to be in place prior to their release and arrangements made to have them registered with a GP immediately (so as to provide a conduit to community mental health services) ”
Source location
Scott Patrick Carton · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Shortcomings in internal information passage concerning the release of prisoners receiving mental health care

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

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

Concerns raised1

Lack of liaison between prison medical services and local psychiatric services for prisoners with ongoing psychiatric issues at release

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

Concerns raised2

Failure of some mental healthcare trusts to accept referrals for homeless prisoners on release

Lack of practical national guidance for continuity of prisoners’ healthcare on release

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

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

Concerns raised1

Failure to ensure access to GP and community mental health services for people released from prison

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

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

Concerns raised2

Failure to arrange immediate GP registration after release

Failure to establish appropriate support services before release

Stated actions 1

Respondent positions 1

Stated actions 9

Stated actions 3

Respondent positions 1

Stated actions 1

Respondent positions 1