Recurring concern

Unreliable completion and transfer of Prisoner Escort Records

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First reported 6 Jan 2014•Latest report 21 Jun 2023

Definition

What this concern includes

Includes failures in the dedicated Prisoner Escort Record process, including staff preparation for completing PERs, completion of escort handover details, accurate identification of accompanying police risk assessments and other documents, transfer of those documents to escort or receiving staff, and verification that the PER information is complete and available.

Not included

  • Excludes generic custody training, handover or record-keeping deficiencies that are not specifically part of the Prisoner Escort Record process.
  • Excludes clinical assessment, treatment, observation or general prisoner-transfer failures where the PER process is not the deficient control.
  • Excludes failures involving police or custody documents that are not recorded as part of, or intended to accompany, a Prisoner Escort Record.
  • Excludes downstream care or escort decisions made after complete and accessible PER information has been reliably provided.
Reports
10

Distinct published reports

Individual concerns
14

A report can raise multiple concerns

Date range
2014–2023

First to latest report issue date

Stated actions
20

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.

GeoAmey PECS Limited3
HM Prison and Probation Service2
South Yorkshire Police2
Bullingdon Prison1
Cardiff Prison1
Care UK1
Central and North West London NHS Foundation Trust1
Department for Education1
Dyfed-Powys Police1
Government Legal Department1
Greater Manchester Police1
Hampshire and Isle of Wight Constabulary1
Herefordshire and Worcestershire Health and Care NHS Trust1
Home Office1
Medacs Healthcare Limited1

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. Worcestershire

    AI-generated summary

    Matthew David Harris · 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

    Matthew David Harris was found suspended in his cell at HMP Long Lartin on 27 May 2022 and died from his injuries at Alexandra Hospital, Redditch, on 29 May 2022. The inquest concluded that he died by suicide. The principal concern was that recent suicidal ideation disclosed during a police interview was not recorded on the documents accompanying him between police custody, court and prison, potentially leading to the risk of suicide or self-harm being underestimated or ignored.

    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 record suicidal ideation on Person Escort Records and Suicide and Self-Harm Warning forms

    Wider context from the report

    “(1) Following his arrest, and before he was interviewed about the alleged offence of murder, Mr. Harris was assessed by a consultant forensic psychiatrist, ████████ concluded that Mr. Harris was fit to be detained and fit to be interviewed, he did not possible symptoms of Post Traumatic Stress Disorder, likely due to some trauma in Mr. Harris’ background, possible symptoms of a personality disorder, and “potentially a psychotic process, with potential underlying delusional beliefs”; (2) During his police interview on 14.5.22, when describing his movements before the alleged murder had taken place, Mr. Harris told officers he had ████████ intending to jump off in order to take his own life, but had decided against it because “I thought no, I’ve got to reveal all this first”; (3) Despite the fact that these comments revealed very recent suicidal ideation on Mr. Harris’ part, no mention of them appears to have been made in any of the following documents: (a) The Person Escort Record ( PER ) and Suicide and Self-Harm ( SASH ) Warning forms which accompanied Mr. Harris from police custody at Haverfordwest Police Station to Haverfordwest Magistrates’ Court on 16.5.22; (b) The PER and SASH Warning forms which accompanied Mr. Harris from Haverfordwest Magistrates’ Court to HMP Swansea later that same day. (4) Although I was quite satisfied that the omission of these comments from the above documents made no difference to the sad outcome in this case, I am concerned that the failure by Dyfed-Powys Police officers to realise that such comments ought to be included on a PER and SASH Warning form, if repeated in future, may lead to a person in custody’s risk of suicide and/or self-harm, being either underestimated, or ignored completely. ”

    Source location

    Matthew David Harris · 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

    Inform investigation and custody staff, anonymously, about the omission of relevant suicidal-ideation information.

    Verbatim wording from the response

    “To confirm, on 1st August 2023 via my Head of Custody Services, all staff involved in investigations and those responsible for the care of detainees whilst in police custody have been informed, in an anonymized manner, of the nature of the omission in this case.”

    Source location

    Response from Dyfed-Powys Police
    Page 2 · response
    Published 6 September 2023

    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

    Instruct custody officers to ask interviewing officers about information relevant to ongoing detainee risk assessment.

    Verbatim wording from the response

    “Custody Officers have been instructed to specifically ask interviewing officers whether they have any information that is relevant to the ongoing duty of risk assessment; information needed to best manage the welfare of the detainee.”

    Source location

    Response from Dyfed-Powys Police
    Page 2 · response
    Published 6 September 2023

    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

    Remind investigators to inform custody officers about disclosures relevant to ongoing risk management.

    Verbatim wording from the response

    “Further, investigators have been reminded of their duty to inform the custody officer of any information disclosed to them that should be considered as part of ongoing risk management.”

    Source location

    Response from Dyfed-Powys Police
    Page 2 · response
    Published 6 September 2023

    Open published response
  2. Central Hampshire

    AI-generated summary

    Michael Folley · 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

    Michael Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.

    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 Detention Officer PER training is completed

    Wider context from the report

    “c) Detention Officer PER training may not have been completed if a DO had many years of experience in the police force which would give what he referred to as “grandfather rights”. ”

    Source location

    Michael Folley · Prevention of Future Deaths report
    Page 4 · 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 ensure secure handover of PER documentation

    Wider context from the report

    “e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry. This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded. f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody officers. ”

    Source location

    Michael Folley · Prevention of Future Deaths report
    Page 4 · 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 of court custody staff to contribute relevant risk information to the PER

    Wider context from the report

    “I am concerned that the impression created was that GEOAmey staff do not actively engage in and contribute to the contents of the PER to highlight any information relevant to risk assessment irrespective of what source it comes from. In addition, there was apparently no log of ████████ call to the court cells. The electronic PER had been checked and nothing was logged. There is no reason to believe ████████ call was not made and it is of concern that there was no apparent system for logging such a call let alone action in the contents of her request. ”

    Source location

    Michael Folley · Prevention of Future Deaths report
    Page 5 · 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

    Mandate PER e-learning for all Custody and Detention Officers and track completion to 100%.

    Verbatim wording from the response

    “Hampshire Constabulary will mandate that all Custody Officers and Detention Officers undertake the force endorsed electronic self-learning package on PERs, irrespective of when they last completed it. The content of the course will be reviewed annually by the Force Custody Senior Management Team (Force Custody) to ensure it remains accurate and fit for purpose thereby ensuring that officers are appropriately trained in”

    Source location

    2019-0230-Response-by-Hampshire-Constabulary
    Page 1 · response
    Published 18 July 2019

    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

    Recommend that Learning and Professional Development review the initial custody course’s PER lesson plan and content against the notice and professional guidance.

    Verbatim wording from the response

    “PER training is already included in the initial custody course for both Custody Officers and Detention Officers. A recommendation will be made to the Learning and Professional Development department who deliver the course to review the current lesson plan and course content to ensure it meets the requirements of this Regulation 28 Notice and guidance contained within the College of Policing Authorised Professional Practice.”

    Source location

    2019-0230-Response-by-Hampshire-Constabulary
    Page 2 · response
    Published 18 July 2019

    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 which Detention Officers completed an initial custody course.

    Verbatim wording from the response

    “In conjunction with the Learning and Professional Development department, Force Custody will conduct a review to establish those Detention Officers who were undertook an initial custody course. Consideration is being given to ensure that those identified undertake the course at the earliest opportunity.”

    Source location

    2019-0230-Response-by-Hampshire-Constabulary
    Page 2 · response
    Published 18 July 2019

    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 next custody newsletter to reinforce PER completion, inspection, warning-page, envelope, risk-marker and external-information responsibilities.

    Verbatim wording from the response

    “Force Custody publishes a quarterly newsletter to all custody officers and detention officers. The next publication is due in September 2019 and will reinforce the issues addressed in this Regulation 28 Notice.”

    Source location

    2019-0230-Response-by-Hampshire-Constabulary
    Page 2 · response
    Published 18 July 2019

    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

    All detention officers had received PER training during the previous two years; only some may not have completed initial custody training.

    Verbatim wording from the response

    “2. Under Section 5, at paragraph 1(c) it outlines that, ‘Detention officer PER training may not have been completed….’ However, all detention officers have received PER training over the last two years. ████████ stated that detention officer initial training may not have been completed if the detention officer had many prior years of experience in policing. The difference here is between initial training and PER training.”

    Source location

    2019-0230-Response-by-Hampshire-Constabulary
    Page 1 · response
    Published 18 July 2019

    Open published response
  3. Inner North London

    AI-generated summary

    Tedros Habtom KAHSSAY · 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

    Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring first aid.

    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 transfer person escort and forensic medical records to nurse reception screening

    Wider context from the report

    “1. The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr Kahssay to HMP Pentonville did not accompany him to nurse reception screening. ”

    Source location

    Tedros Habtom KAHSSAY · 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

    Require nurses to confirm they have seen the person escort record and possess the CSRA and PER before completing reception screening.

    Verbatim wording from the response

    “As you heard in evidence at the inquest, the reception screening template has been changed. The change that has been implemented is a control question in the first reception screen which is a mandatory field so the nurse needs to stop and answer the question. It asks if the nurse has seen the PER. All nursing staff have been instructed and are aware that they are not to screen any prisoner without a CSRA and PER as minimum requirement to aid screening.”

    Source location

    2016-0437-Response-by-Care-UK.pdf
    Page 1 · response
    Published 6 December 2016

    Open published response
  4. Worcestershire

    AI-generated summary

    Matthew Colin SARGENT · 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

    Matthew Colin SARGENT was a serving prisoner who died in his cell at some time between 25 and 26 September 2014. The jury concluded that he committed suicide and raised concerns about the systematic, accurate and clear sharing of historical and current information between prison and healthcare departments.

    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 supply Prisoner Escort Records to Healthcare staff at reception

    Wider context from the report

    “(4) There was a concern that the Prisoner Escort Record (highlighting concerns and risks) was not supplied to the Healthcare Department and nurses at reception. It was suggested that this should be an imperative requirement for the further sharing of relevant information. ”

    Source location

    Matthew Colin SARGENT · 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

    Remind prison and healthcare staff to check the PER every time and escalate unavailable records through a Datix incident report.

    Verbatim wording from the response

    “In order to ensure robust communication and partnership working going forward we will continue to work closely with our prison partners on this and in particular, the Head of Healthcare is working to address the concern with the Safer Custody Governor. In addition, all (prison and healthcare) staff have been reminded that they must see the PER on every occasion and that non-access should be escalated within the prison via a datix incident report. If the staff member does not have access, an incident form should be completed as soon as it is apparent that a PER isn’t available.”

    Source location

    Matthew-Sargent-Response
    Page 3 · response
    Published 7 April 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

    Prison Service staff are responsible for examining and sharing PER and ACCT information with healthcare staff.

    Verbatim wording from the response

    “These two points raise similar issues and can be answered together. It is the responsibility of prison service staff to share information with other departments and agencies both internal and external. PSI 74/2011 (First Days in Custody) sets out the requirement for the Person Escort Record (PER) form to be examined in Reception by prison staff to identify any immediate needs and risks and for this information to be forwarded to other staff and agencies as necessary, including healthcare. PSI 74/2011 sets out the mandatory requirements for prison staff and healthcare in respect of a prisoner’s ACCT status, ACCT alerts and risk assessments. Care UK thus expects PSI 74/2011 to be followed and that prison personnel will record a prisoner’s ACCT status on their record and share this and any concerns with Healthcare.”

    Source location

    Matthew-Sargent-Response
    Page 3 · response
    Published 7 April 2016

    Open published response
  5. South Yorkshire (Western)

    AI-generated summary

    Neil Budziszewski · 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

    Neil Budziszewski was arrested for theft while intoxicated and detained overnight at Ecclesfield Police Station after being charged. He was found dead in his cell before being transferred to court. The report identified numerous failures involving risk assessment, communication and handovers, monitoring, recording, and obtaining medical assessment, including failures to recognise and respond to the risks of acute alcohol withdrawal syndrome.

    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 complete Prison Escort Forms for detainee transfers

    Wider context from the report

    “(2) The afternoon custody sergeant failed to complete a Prison Escort Form for a transfer to Bridge Street (for LiveScan identification) in breach of guidance. Similarly, whilst the receiving custody sergeant at Bridge Street commenced a custody record and completed a risk assessment, he also failed to complete a Prison Escort Form for the transfer back. ”

    Source location

    Neil Budziszewski · 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

    Review the Prisoner Escort Form policy and inform custody staff that forms are required for all detainee transfers.

    Verbatim wording from the response

    “It would appear that this was a commonly misunderstood form across South Yorkshire Police with custody staff believing that the PER form was only required where a detainee was being transferred to the custody of another agency and not internally. Following the outcome of the inquest touching upon the death of Mr Neil Budziszewski the policy has been reviewed and all custody staff have been informed of the requirement for this form to be completed when transferring a prisoner between custody suites or police stations as well as when transferring to an external agency. This will be followed up with a written notification to all custody staff explaining the need for this form to be completed whenever a detainee is moved from custody regardless of the agency transferring the detainee.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 1 · response
    Published 23 March 2015

    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

    Circulate written notification explaining that Prisoner Escort Forms must be completed whenever detainees move from custody.

    Verbatim wording from the response

    “It would appear that this was a commonly misunderstood form across South Yorkshire Police with custody staff believing that the PER form was only required where a detainee was being transferred to the custody of another agency and not internally. Following the outcome of the inquest touching upon the death of Mr Neil Budziszewski the policy has been reviewed and all custody staff have been informed of the requirement for this form to be completed when transferring a prisoner between custody suites or police stations as well as when transferring to an external agency. This will be followed up with a written notification to all custody staff explaining the need for this form to be completed whenever a detainee is moved from custody regardless of the agency transferring the detainee.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 1 · response
    Published 23 March 2015

    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

    Retrain custody Inspectors and reiterate Prisoner Escort Form completion requirements and required transfer details to custody staff.

    Verbatim wording from the response

    “As referred to in paragraph two, there appear to have been a number of misunderstandings around the Prisoner Escort Form. These errors have now been retrained to custody Inspectors and will be reiterated to custody staff and the details to be included by 31 May 2015.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 7 · response
    Published 23 March 2015

    Open published response
  6. South Yorkshire (Western)

    AI-generated summary

    Peter Stanley · 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

    Peter Stanley, aged 17, was found hanging in woodland on 2 August 2013 after a history of mental health concerns, suicidal thoughts and a previous suicide attempt. The report identified missed opportunities for mental health assessment and care, alongside concerns about information-sharing, homelessness and accommodation, custody assessments, and support for young people.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to routinely provide prisoner escort records to the Youth Offending Service

    Wider context from the report

    “(5) A prisoner escort record (known commonly as a PER) would have been handed over from the police to the privatised court detention officers when Peter was produced before the magistrates. This contains details (inter alia) of risks, self harm issues, medical attention and warning markers. I understand that the Youth Offending Service believe that the PER should be routinely given to them it would inform assessments as to the immediate needs of the young person. This would only arise, of course, in the relatively few cases where the young person has spent a period in police cells. ”

    Source location

    Peter Stanley · Prevention of Future Deaths report
    Page 4 · 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

    Review contractor operational policies to ensure staff understand and follow prisoner escort record information-sharing requirements.

    Verbatim wording from the response

    “I can confirm that PECS entirely accepts your recommendation and we have reviewed our contractor’s operational policies to ensure that their staff understand and adhere to this in future.”

    Source location

    2014-0390-Response-by-NOMS
    Page 1 · response
    Published 2 September 2014

    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

    Remind contractor staff that Youth Offending Service employees may access relevant Prisoner Escort Record information.

    Verbatim wording from the response

    “The content of the PER form can be shared with any appropriate party who needs access to the prisoner in order to conduct interviews or assessments. We have taken steps to remind Geo Amey that employees of the Youth Offending Service clearly fall into this category. This will be reinforced in staff briefings and safer custody training going forward.”

    Source location

    2014-0390-Response-by-NOMS
    Page 2 · response
    Published 2 September 2014

    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

    Reinforce Youth Offending Service information-sharing responsibilities through staff briefings and safer custody training.

    Verbatim wording from the response

    “The content of the PER form can be shared with any appropriate party who needs access to the prisoner in order to conduct interviews or assessments. We have taken steps to remind Geo Amey that employees of the Youth Offending Service clearly fall into this category. This will be reinforced in staff briefings and safer custody training going forward.”

    Source location

    2014-0390-Response-by-NOMS
    Page 2 · response
    Published 2 September 2014

    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 the format and content of the Prisoner Escort Record with the Ministerial Council on Deaths in Custody.

    Verbatim wording from the response

    “NOMS is currently reviewing the format and content of the PER form as part of our work with the Ministerial Council on Deaths in Custody. I will ensure that the findings of this inquest are communicated to the NOMS team involved in this work.”

    Source location

    2014-0390-Response-by-NOMS
    Page 2 · response
    Published 2 September 2014

    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

    Communicate the inquest findings to the NOMS team reviewing the Prisoner Escort Record.

    Verbatim wording from the response

    “NOMS is currently reviewing the format and content of the PER form as part of our work with the Ministerial Council on Deaths in Custody. I will ensure that the findings of this inquest are communicated to the NOMS team involved in this work.”

    Source location

    2014-0390-Response-by-NOMS
    Page 2 · response
    Published 2 September 2014

    Open published response
  7. Oxfordshire

    AI-generated summary

    Marcin Jack STOGA · 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

    Marcin Stoga had been held on remand at HMP Bullingdon since November 2012 and was found hanging in his cell on 24 April 2013, the day after attending court. Concerns included information about a previous overdose not being available during his initial assessment, and prisoners with mental health difficulties or a medium/high risk of self-harm not being routinely assessed after returning from court. The inquest jury confirmed suicide and identified missed opportunities to support him that were systemic in nature.

    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 make relevant prisoner escort information available for initial assessments

    Wider context from the report

    “(1) Prior to Mr Stoga’s arrival at HMP Bullingdon, there was a Prisoner Escort Record which referred to the fact that Mr Stoga had taken an overdose in 2012. It appears that this form and this information was not available to the Prison Officers or the Healthcare Nurse who initially assessed Mr Stoga upon his arrival. One would have thought that the form or at least the information on the form should routinely be available to those responsible for carrying out initial assessments of this nature. ”

    Source location

    Marcin Jack STOGA · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement and routinely use a reception checklist to acknowledge risk information and support self-harm and suicide risk assessment after court returns.

    Verbatim wording from the response

    “In your Regulation 28 report, you expressed your concern that on Mr Stoga’s arrival at HMP Bullingdon, the Prisoner Escort Record (PER) was not shared with prison officers or healthcare staff who initially interviewed and assessed Mr Stoga. The PER is the key document for ensuring that information about the risks posed to and by prisoners on external movement from prisons or transferred within the criminal justice system is available to those responsible for their custody. I am aware that you invited submissions on your draft Regulation 28 report to which the Treasury Solicitor responded on 18 July confirming that since the inquest into the death of Mr Stoga, the Deputy Governor had put in place a checklist to assist in the assessment of risk of self-harm and suicide.”

    Source location

    2014-0576-Response-by-NOMS
    Page 1 · response
    Published 21 July 2014

    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

    Trial revised national and local Prisoner Escort Records in the South Central Area, incorporating suicide and self-harm alerts and prominent red-flag risk information pages.

    Verbatim wording from the response

    “You will, I am sure be interested to know that a Pilot Regional PER forum has met twice in the second part of this year at HMP Winchester attended by a wide range of key stakeholders and operational practitioners. The forums remit is to consider and develop improvements to the PER whilst addressing the recommendations from the HMIP Thematic Review and related ones from the Independent Police Complaints Commission and HM Coroners in response to deaths in custody. Whilst the Regional forum reports to a National Steering Group there has been much progress and it is intended to trial two revised PER’s in the South Central Area in early 2015. The first is a “National” PER document for use by court escorts and for inter prison transfers and a “Local” PER for use in hospital and Police escorts.”

    Source location

    2014-0576-Response-by-NOMS
    Page 1 · response
    Published 21 July 2014

    Open published response
  8. Cardiff & the Vale of Glamorgan

    AI-generated summary

    Christopher Shapley · Prevention of Future Deaths report

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

    Report summary

    Christopher Shapley was arrested on 17 September 2013, remanded in custody, and taken to HMP Cardiff after treatment at hospital for alcohol withdrawal symptoms and fitting. He was placed alone in a cell and found hanged during morning checks on 20 September 2013. Concerns included incomplete transfer of information about his hospital treatment and self-harm risks, insufficient assessment of risk factors, inadequate efforts to arrange a shared cell, and inadequate handover and night-time observations.

    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 medical or hospital treatment information in the Person Escort Record

    Wider context from the report

    “(1) The jury found it of concern that the information that Christopher Shapley had been in Prince Charles Hospital after arrest was not known to the prison. Had it been known his condition may, they felt, have been treated more seriously and he would have been kept under greater observation. There would seem to be no reason why the PER (Person Escort Record) could not contain a section dealing with medical or hospital treatment received while in police custody prior to remand (e.g. the section at the foot of page 2 could also include a prompt for any health treatment received). This information will not only advise prison staff of the current medical circumstances of the prisoner but will also prompt them to call for any hospital discharge notes (or consult with the Force Medical Examiner) so that effective treatment can be continued. ”

    Source location

    Christopher Shapley · 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 securely attach warning documents to the Person Escort Record

    Wider context from the report

    “(2) The PER form had a number of staple holes where extra documents had been attached. It is evident that one of these documents was a warning form prepared by a police officer enumerating the risk factors affecting Christopher Shapley. This document would have been material assistance to the prison staff, but had become detached before it reached them. A system of stapling documents to the PER is prone to human error and accidental detachment. It would appear possible for a system to be devised that ensured that any such warning form should stay securely with the PER. ”

    Source location

    Christopher Shapley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  9. West London

    AI-generated summary

    Lee Sean MACPHERSON · 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

    Lee Sean MACPHERSON was found dead in a safer custody cell at HMP Wormwood Scrubs on 17 October 2012, after being remanded into custody the previous afternoon. Concerns related to incomplete and inconsistently transferred police risk-assessment and escort handover documentation between the police, SERCO and prison staff.

    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 complete escort handover details on the PER

    Wider context from the report

    “(3) The escort handover details on the PER were not completed by the prison staff (or SERCO staff which is a matter SERCO have already addressed). ”

    Source location

    Lee Sean MACPHERSON · Prevention of Future Deaths report
    Page 1 · 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 ensure that police documentation recorded as accompanying the PER is available to escort staff

    Wider context from the report

    “(2) There was a lack of common understanding between SERCO staff and prison staff about what police documentation, including the police risk assessment, accompanied a person in custody, in addition to the PER. Boxes on the PER had been ticked indicating that, among other things, it was accompanied by a police risk assessment but SERCO staff said they had not seen that or the other documents. ”

    Source location

    Lee Sean MACPHERSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  10. Manchester South

    AI-generated summary

    Billy Paul Thomas Salton · 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

    Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort information.

    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 complete prisoner transfer documentation accurately

    Wider context from the report

    “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy. 2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is. 3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record. 4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted. 5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters. 6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate. 7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen. 1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy). 2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody. 3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked. 4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded. 1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody. 2. Staff should be reminded that all cell checks should be accurately documented. 3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY. ”

    Source location

    Billy Paul Thomas Salton · 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

    Issue and check improved guidance for sergeants on completing, timing and signing off Prisoner Escort forms.

    Verbatim wording from the response

    “Since your observations we have put out improved guidance on completion of the PER form to sergeants which include what to record, when it is to be done and how it is to be signed off. This has been extensively checked and has led to improvements in standards.”

    Source location

    2014-0002-Response-by-Greater-Manchester-Police
    Page 3 · response
    Published 6 January 2014

    Open published response
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Data last updated 7 September 2026