Recurring concern

Unreliable second prison reception health screening

First to latest report 26 Jul 2016 — 13 Jul 2017

Reports that mention this concern
3
Times this concern has been raised
4
Stated actions linked to this concern
2

What this concern includes

Includes failures in the prison process for completing and following up the second health screening after reception, including delayed or omitted screening, failure to ensure the person is brought for screening, and failure by healthcare staff to pursue a missed screening.

What is not included
  • Excludes the initial prison reception health screening unless the assertion also concerns the second post-reception screening process.
  • Excludes generic prison healthcare delays, risk assessments or information-transfer failures where the second reception health screening is not the deficient process.
  • Excludes clinical care or treatment after the second screening has been completed and its findings are available.
  • Excludes unrelated prison observation, ACCT, detoxification-placement and custody-transfer processes.

Reports and published responses 3 reports

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

  1. Liverpool and the Wirral

    AI-generated summary

    Edwin Lewis O'Donnell · 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

    Edwin Lewis O'Donnell died on 23 October 2016 after being found unresponsive and hanging by a ligature from his cell tap; resuscitation was unsuccessful. The inquest found that his accidental death was contributed to by neglect, including failures to conduct an ACCT review, act on a referral for a mental health assessment, and escalate information that he had said he would be dead by 8.00 p.m.

    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

    Delays in completing the second health screening after reception

    Wider context from the report

    “During the course of the inquest into the death of Edwin Lewis (Ned) O’Donnell it was apparent that a nurse carrying out the first health reception screening was not given access to the PER (Prisoner Escort Report) which had accompanied the prisoner from another prison establishment. a) The PER form had content which was pertinent to mental wellbeing which was inconsistent with the information provided by Ned. b) Though the previous prison indicated that they had sent a print from the digital IMR System One the nurse conducting the first health reception screening had no recollection or notes to indicate whether this was available at the time of the screening. c) There is expected to be a second health screening of inmates some 24 to 48 hours later – which enables information from the community to be received and fuller informed access to the digital IMR System One. In this case the second screening was not until the 27th March 2016. Whereas the first screening was on the 9th March 2016. d) An offender supervisor (Probation) working in the prison has been ACCT trained but did not know that there was a low threshold for opening an ACCT The Court considers that in other cases important information in assessing risk could be missed if action is not taken to remedy these matters by making it a requirement that prison discipline staff record on C-Nomis all documentation received with a prisoner in particular • PER forms • SASH forms • Printed summaries from System One • Prescriptions C-Nomis should also be noted that these have been handed to (or copies have been handed to healthcare in reception. It could also be a mandated requirement that the digital IMR System One be updated (possibly when the digital IMR System Two is rolled out if that is imminent) with forced fields to ensure that nurses carrying out the first health reception screening record the documentation provided by the Prison staff which accompanied the prisoner. The Court has heard evidence of the new training developed for the ACCT protocol and that this is being rolled out in a prioritised manner within HMP Liverpool. The Court considers it important that the Probation service takes responsibility to ensure that (offender managers and supervisors) probation staff working within prisons all receive basic ACCT training. Probation staff often have to break unwelcome news and this must require a risk assessment of the effects of that news on inmates. ”

    Source location

    Edwin Lewis O'Donnell · 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

    Re-evaluate current practices and implement revised procedures to ensure second health screenings occur within 24–48 hours.

    Verbatim wording from the response

    “Timing of the Second Health Screening Your second concern relates to the delay in Mr O’Donnell’s second health screening. I understand that the Head of Healthcare at Liverpool and a member of the prison’s senior management team are meeting shortly to re-evaluate current practices and implement revised procedures to ensure that second health screenings take place within 24-48 hours.”

    Source location

    2017-0258-Response-by-HM-Prison-Probation-Service
    Page 3 · response
    Published 29 November 2017

    Open published response

  2. Inner North London

    AI-generated summary

    John WILLIAMS · Prevention of Future Deaths report

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

    Report summary

    John Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among prison officers.

    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 follow up missed second reception screens

    Wider context from the report

    “2. There was no second reception screen conducted. If Mr Williams was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up. ”

    Source location

    John WILLIAMS · 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 conduct the second reception screen

    Wider context from the report

    “2. There was no second reception screen conducted. If Mr Williams was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up. ”

    Source location

    John WILLIAMS · 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

    Maintain a register of missed Second Reception/Wellman assessments, arrange follow-up appointments through the Lead Nurse, and document patient refusals with scanned disclaimers.

    Verbatim wording from the response

    “As you heard in evidence, it is the case now that a register is kept of any Second Reception/Wellman assessments that are not completed. It is then the responsibility of the Lead Nurse to arrange for the”

    Source location

    Response from Care UK
    Page 1 · response
    Published 6 April 2017

    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 Lead Nurse is responsible for arranging follow-up and completion of missed Second Reception/Wellman assessments.

    Verbatim wording from the response

    “As you heard in evidence, it is the case now that a register is kept of any Second Reception/Wellman assessments that are not completed. It is then the responsibility of the Lead Nurse to arrange for the”

    Source location

    Response from Care UK
    Page 1 · response
    Published 6 April 2017

    Open published response

  3. Inner North London

    AI-generated summary

    Terence Darren ADAMS · 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

    Terence Darren Adams committed suicide by hanging himself in his cell at HM Prison Pentonville. Concerns included failures in checking prison escort records, understanding and acting on the first night reception template, exploring his suicidal history, ensuring attendance at a follow-up reception screen, and sharing the root cause analysis needed for learning lessons.

    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 follow up non-attendance at the second reception screen

    Wider context from the report

    “5. On the morning he died, Mr Adams should have attended his second reception screen, also known as the well man clinic. When he did not arrive, the healthcare nurse did not attempt to find out why or to secure his attendance. ”

    Source location

    Terence Darren ADAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Nurses cannot chase prisoners who miss appointments during clinics because workload makes this impractical and inefficient.

    Verbatim wording from the response

    “When a patient is booked for a clinic but does not attend (DNA), nurses will investigate and chase up that person once the clinic is over. It would not be possible, nor an efficient use of clinical time, for nurses to chase up prisoners during the course of a clinic. With 15-20 new receptions everyday (Pentonville being a remand prison and thus having a high population turnover), if nurses chased up DNA prisoners during the course of the clinic, they would spend their time doing nothing else.”

    Source location

    Response from Care UK
    Page 4 · response
    Published 26 July 2016

    Open published response

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

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Data last updated 7 September 2026