Recurring concern

Inadequate care and supervision provision for prisoners with complex needs

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First reported 7 Nov 2014•Latest report 24 Nov 2025

Definition

What this concern includes

Includes failures of arrangements specifically intended to provide or coordinate care and supervision for prisoners with complex physical or mental health needs, including absence of suitable facilities or support, unclear provider responsibility, and gaps in assistance with daily living, mental-health care or out-of-hours support.

Not included

  • Excludes generic prison staffing, training, healthcare access or supervision deficiencies unless they directly leave prisoners with complex physical or mental health needs without suitable care and supervision.
  • Excludes ordinary prison healthcare or custodial supervision concerns that do not involve complex care needs requiring a coordinated or specialised provision.
  • Excludes failures limited to a specific clinical treatment, referral, handover or information-sharing process where inadequate care and supervision provision is not the shared unsafe condition.
  • Excludes care and support gaps for non-prisoners or for prisoners without materially complex physical or mental health needs.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
3

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England4
Department of Health and Social Care2
HM Prison and Probation Service2
Nottingham Prison1
Nottinghamshire Healthcare NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Surrey

    AI-generated summary

    Diana Ocean Grant · 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

    Diana Ocean Grant, who was experiencing a relapse of paranoid schizophrenia and symptoms of psychosis, died in her prison cell after a foreign object became lodged in her upper airway. The report identified concerns about failures and delays in mental health assessment, treatment, information-sharing, observation and prison placement, as well as the limited availability of secure mental health beds for people requiring admission.

    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

    Inability of prison healthcare provision to fully meet mental health patients’ needs

    Wider context from the report

    “The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise. The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate, but also because of an expectation that some element of pre-planning will take place before such an admission occurs. Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days. Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing. This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments. Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison. The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed. ”

    Source location

    Diana Ocean Grant · Prevention of Future Deaths report
    Page 6 · 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

    Complete an independent review of HMP Bronzefield healthcare provision and submit its findings to the Prisons and Probation Ombudsman.

    Verbatim wording from the response

    “An independent review of the healthcare provision at HMP Bronzefield was commissioned and submitted to the Prisons and Probation Ombudsman (PPO) in February 2023. The PPO’s final report was published in January 2025. Alongside Sodexo, the Clinical Lead for Central and North West London NHS Foundation Trust was involved with developing an action plan in May 2023 and this was submitted to the PPO.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 1 December 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

    Develop and submit an action plan addressing findings from the HMP Bronzefield healthcare review.

    Verbatim wording from the response

    “An independent review of the healthcare provision at HMP Bronzefield was commissioned and submitted to the Prisons and Probation Ombudsman (PPO) in February 2023. The PPO’s final report was published in January 2025. Alongside Sodexo, the Clinical Lead for Central and North West London NHS Foundation Trust was involved with developing an action plan in May 2023 and this was submitted to the PPO.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 1 December 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

    Existing local actions are considered appropriate to address the healthcare issues identified at HMP Bronzefield.

    Verbatim wording from the response

    “NHS England has advised that, since April 2023, its South East Health and Justice team has commissioned the full healthcare provision at HMP Bronzefield, including primary care, substance misuse and mental health services. An independent review of healthcare provision at the prison was completed and submitted to the Prisons and Probation Ombudsman in February 2023, and an action plan was subsequently developed with the provider to address the findings. NHS England has confirmed that the London Region is satisfied that appropriate actions have been taken locally in response to the issues identified at inquest.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 1 December 2025

    Open published response

  2. Cheshire

    AI-generated summary

    Kevin Dermott · 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

    Kevin Dermott, who had bipolar affective disorder and was serving a prison sentence, suffered episodes of mental illness while held at several prisons and died by hanging in his cell at HMP Risley on 19 May 2014. The concerns included inadequate mental health and psychiatric care, failures in care planning and communication, and failure to follow ACCT procedures; the jury concluded that deficiencies in mental health care and observation partly contributed to his death.

    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 suitable psychiatric care facilities

    Wider context from the report

    “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”

    Source location

    Kevin Dermott · 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

    Work with specialised commissioning teams and partner organisations to address the shortage of secure psychiatric beds and delays transferring acutely unwell prisoners.

    Verbatim wording from the response

    “NHS England recognises that there is a national issue regarding lack of secure psychiatric beds which impacts on the timely transfer of acutely unwell prisoners. The Health and Justice commissioning team are working with colleagues in the NHS England Specialised Commissioning teams, who are responsible for secure mental health provision, and other partners in Department of Health, National Offender Management Services and Ministry of Justice and Home Office to look at this issue and try to resolve it.”

    Source location

    2016-0220-Response-by-NHS-England
    Page 2 · response
    Published 13 June 2016

    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

    Specialised Commissioning teams are responsible for secure mental health provision, including addressing shortages affecting transfers of acutely unwell prisoners.

    Verbatim wording from the response

    “NHS England recognises that there is a national issue regarding lack of secure psychiatric beds which impacts on the timely transfer of acutely unwell prisoners. The Health and Justice commissioning team are working with colleagues in the NHS England Specialised Commissioning teams, who are responsible for secure mental health provision, and other partners in Department of Health, National Offender Management Services and Ministry of Justice and Home Office to look at this issue and try to resolve it.”

    Source location

    2016-0220-Response-by-NHS-England
    Page 2 · response
    Published 13 June 2016

    Open published response

  3. Nottinghamshire

    AI-generated summary

    Shalan Blackwood · 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

    Shalan Blackwood died at HMP Nottingham on 5 August 2015 as a result of bleeding from a duodenal ulcer. The report identified concerns about inadequate care and supervision for prisoners with complex physical or mental health needs, insufficient staffing for prisoners in segregation requiring a four-person unlock, unclear decision-making tools, widespread use of New Psychoactive Substances, and insufficient recognition of urgent physical symptoms obscured by mental health issues.

    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 proper provision for care and supervision of prisoners with complex physical and/or mental health needs

    Wider context from the report

    “1. That there is no proper provision for the care and supervision of prisoners who present with complex physical and/or mental health needs. It is understood that such a provision could be provided by means of an inpatient unit within the prison, such as for example is the case at HMP Liverpool. ”

    Source location

    Shalan Blackwood · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. West Yorkshire Eastern

    AI-generated summary

    Barry Horrocks · 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

    Barry Horrocks, who had vascular dementia and other physical and mental health problems, was serving a prison sentence at HMP Wakefield when he suffered a cerebral event and died in hospital on 5 April 2013. The principal concern was the lack of coordinated care and suitable support for his deteriorating ability to manage daily living and intimate personal care, including personal hygiene, toileting and medication.

    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 assign responsibility for the care and well-being of prisoners with complex needs

    Wider context from the report

    “(3) Mr Horrocks, by virtue of his condition “fell through the net” in that none of the providers of care including health care had responsibility for a man in his condition. I was informed that assistance with intimate aspects of the activities of daily living were outside the remit of prisoner volunteers; the uniform prison officers; and those who provide primary care such as GPs and nursing staff nor, I was told, was it appropriate for him to be cared for in the Prison Healthcare Centre whether as an in-patient or out-patient. Those who provide mental health care and out of hours care did not accept any responsibility for his well-being. ”

    Source location

    Barry Horrocks · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026